{"id":1232,"date":"2025-10-20T20:38:19","date_gmt":"2025-10-20T20:38:19","guid":{"rendered":"https:\/\/animalclinicww.com\/?page_id=1232"},"modified":"2025-10-23T20:35:26","modified_gmt":"2025-10-23T20:35:26","slug":"admission-form","status":"publish","type":"page","link":"https:\/\/animalclinicww.com\/?page_id=1232","title":{"rendered":"Admission Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1232\" class=\"elementor elementor-1232\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-362ce462 e-flex e-con-boxed e-con e-parent\" data-id=\"362ce462\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4fda9d elementor-widget elementor-widget-text-editor\" data-id=\"4fda9d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\n                <div class='gf_browser_gecko gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_1' style='display:none'><style>#gform_wrapper_1[data-form-index=\"0\"].gform-theme,[data-parent-form=\"1_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 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79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Hospital Admission Form<\/h2>\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_1'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F1232' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_49\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><table width=\"100%\" cellpadding=\"0\" cellspacing=\"0\" border=\"0\">\n  <tr>\n    <!-- Column 1: Logo and Clinic Name -->\n    <td width=\"33%\" valign=\"top\" align=\"left\">\n      <img decoding=\"async\" src=\"https:\/\/animalclinicww.com\/wp-content\/uploads\/2025\/10\/Logo-Small-180.png\" alt=\"Animal Clinic Logo\" style=\"display: block;\">\n      <h4>ANIMAL CLINIC OF WALLA WALLA<\/h4>\n    <\/td>\n    \n    <!-- Column 2: Address and Contact Info -->\n    <td width=\"34%\" valign=\"top\" align=\"center\">\n      <p>2089 Taumarson Road<br>\n      Walla Walla, WA 99362<br>\n      Phone (509) 525-6111   Fax (509) 525-6102<br>\n      info@animalclinicww.com<\/p>\n    <\/td>\n    \n    <!-- Column 3: Veterinarians -->\n    <td width=\"33%\" valign=\"top\" align=\"right\">\n      <p>Bret K. Smith, DVM<br>\n      Alexandra Colton-Ashcraft, DVM<br>\n      Daniel Prendiville, DVM<\/p>\n    <\/td>\n  <\/tr>\n<\/table><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-five-twelfths 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_1_5'>Today\u2019s 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_5' id='input_1_5' type='text' value='04\/05\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_5_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_5_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_5' class='gform_hidden' value='https:\/\/animalclinicww.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-seven-twelfths 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_1_7'>Pet\/Animal 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_1_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-five-twelfths 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_1_8'>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_8' id='input_1_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_9\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_9' id='input_1_9' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>Telephone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_1_10' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>Why is your pet here today?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_11' id='input_1_11' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>How long has this condition persisted?<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_15\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-half 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 gfield_label_before_complex' >May we sedate your pet if necessary?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_15'>\n\t\t\t<div class='gchoice gchoice_1_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Yes'  id='choice_1_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_0' id='label_1_15_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No'  id='choice_1_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_1' id='label_1_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_16\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-half 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 gfield_label_before_complex' >May we perform blood work if necessary?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_16'>\n\t\t\t<div class='gchoice gchoice_1_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Yes'  id='choice_1_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_16_0' id='label_1_16_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='No'  id='choice_1_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_16_1' id='label_1_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_17\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-full 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 gfield_label_before_complex' >May we take x-rays if necessary?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_17'>\n\t\t\t<div class='gchoice gchoice_1_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Yes'  id='choice_1_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_17_0' id='label_1_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='No'  id='choice_1_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_17_1' id='label_1_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_18\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_1_18'>If your pet on any medications?  If so, what type and how often?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_18' id='input_1_18' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_19\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_1_19'>Did your pet have these medications today?  If so, at what time?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_19' id='input_1_19' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_22\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >If your pet is found to have transmissible conditions such as fleas, ticks, ear mites, or fungal infections, the clinic must treat such conditions to prevent spread to other patients.  Admission of your pet to the hospital constitutes permission for treatment of such transmissible conditions and acceptance of financial responsibility for such treatment.  <\/div><fieldset id=\"field_1_23\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-half 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 gfield_label_before_complex' >If vaccinations are not current, would you like to update them today?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_23'>\n\t\t\t<div class='gchoice gchoice_1_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_1_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_23_0' id='label_1_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_1_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_23_1' id='label_1_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_24\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_1_24'>When did your pet last eat?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_1_24' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_27\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Which of the following have you observed in the past week?<\/div><fieldset id=\"field_1_26\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-full 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 gfield_label_before_complex' >Change in activity? If YES, please explain.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_26'>\n\t\t\t<div class='gchoice gchoice_1_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_1_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_26_0' id='label_1_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_1_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_26_1' id='label_1_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_28\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_28'>Explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_1_28' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_29\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-full 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 gfield_label_before_complex' >Loss of appetite? If YES, please explain.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_29'>\n\t\t\t<div class='gchoice gchoice_1_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_1_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_29_0' id='label_1_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_1_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_29_1' id='label_1_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_30\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>Explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_30' id='input_1_30' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_31\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-full 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 gfield_label_before_complex' >Excessive drinking? If YES, please explain.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_31'>\n\t\t\t<div class='gchoice gchoice_1_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_1_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_31_0' id='label_1_31_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_1_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_31_1' id='label_1_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_32\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_32'>Explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_1_32' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_33\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-full 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 gfield_label_before_complex' >Abnormal bowel movements ? If YES, please explain.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_33'>\n\t\t\t<div class='gchoice gchoice_1_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Yes'  id='choice_1_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_33_0' id='label_1_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_1_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_33_1' id='label_1_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_34\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_34'>Explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_1_34' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_35\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-full 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 gfield_label_before_complex' >Vomiting? If YES, please explain.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_35'>\n\t\t\t<div class='gchoice gchoice_1_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_1_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_35_0' id='label_1_35_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_1_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_35_1' id='label_1_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_36\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_36'>Explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_36' id='input_1_36' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_37\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-full 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 gfield_label_before_complex' >Straining to urinate? If YES, please explain.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_37'>\n\t\t\t<div class='gchoice gchoice_1_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Yes'  id='choice_1_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_0' id='label_1_37_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='No'  id='choice_1_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_1' id='label_1_37_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_38\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_38'>Explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_38' id='input_1_38' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_39\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-full 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 gfield_label_before_complex' >Increased urination? If YES, please explain.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_39'>\n\t\t\t<div class='gchoice gchoice_1_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Yes'  id='choice_1_39_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_39_0' id='label_1_39_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='No'  id='choice_1_39_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_39_1' id='label_1_39_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_40\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_40'>Explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_40' id='input_1_40' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_41\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-full 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 gfield_label_before_complex' >Coughing? If YES, please explain.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_41'>\n\t\t\t<div class='gchoice gchoice_1_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Yes'  id='choice_1_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_41_0' id='label_1_41_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='No'  id='choice_1_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_41_1' id='label_1_41_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_42\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_42'>Explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_42' id='input_1_42' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_43\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-full 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 gfield_label_before_complex' >Sneezing? If YES, please explain.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_43'>\n\t\t\t<div class='gchoice gchoice_1_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Yes'  id='choice_1_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_43_0' id='label_1_43_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='No'  id='choice_1_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_43_1' id='label_1_43_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_44\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_44'>Explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_44' id='input_1_44' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_45\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_45'>Any additional questions or comments?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_45' id='input_1_45' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_46\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >I give my consent and accept financial responsibility for the procedure(s) performed today.  Even though animals are given a pre-procedure exam, I understand that there are risks involved in the administration of general anesthesia and in performing all surgeries, and therefore I give my permission for treatment of unforeseen conditions which may arise during anesthesia, surgery, and recovery.  \nI understand that payment is due in full upon my pet\u2019s discharge.\n<\/div><fieldset id=\"field_1_47\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >My method of payment will be:<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_1_47'>\n\t\t\t<div class='gchoice gchoice_1_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Check'  id='choice_1_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_47_0' id='label_1_47_0' class='gform-field-label gform-field-label--type-inline'>Check<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Credit or Debit Card'  id='choice_1_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_47_1' id='label_1_47_1' class='gform-field-label gform-field-label--type-inline'>Credit or Debit Card<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_47_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Cash'  id='choice_1_47_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_47_2' id='label_1_47_2' class='gform-field-label gform-field-label--type-inline'>Cash<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_47_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Existing Care Credit Account'  id='choice_1_47_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_47_3' id='label_1_47_3' class='gform-field-label gform-field-label--type-inline'>Existing Care Credit Account<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_48\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_48'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_48' id='input_1_48_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_48_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><canvas id='input_1_48' width='600' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/animalclinicww.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_1_48_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_1_48_resetbutton' 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