{"id":1245,"date":"2025-10-23T20:15:40","date_gmt":"2025-10-23T20:15:40","guid":{"rendered":"https:\/\/animalclinicww.com\/?page_id=1245"},"modified":"2025-10-23T20:26:37","modified_gmt":"2025-10-23T20:26:37","slug":"surgery-and-dentistry-form","status":"publish","type":"page","link":"https:\/\/animalclinicww.com\/?page_id=1245","title":{"rendered":"Surgery And Dentistry Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1245\" class=\"elementor elementor-1245\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4c3d9f6f e-flex e-con-boxed e-con e-parent\" data-id=\"4c3d9f6f\" 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-77493b4c elementor-widget elementor-widget-text-editor\" data-id=\"77493b4c\" data-element_type=\"widget\" data-e-type=\"widget\" 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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-btn-bg-color-hover-tertiary: #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\">Surgery And Dentistry Consent 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_2'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F1245' 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' data-column-layout='fill'><div id=\"field_2_1\" class=\"gfield gfield--type-html gfield--input-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\" data-group-id=\"d65b172d\" data-field-span=\"12\"><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_2_4\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"80a6485b\" data-field-span=\"3\"><label id='gfield_label_2_4' class='gfield_label gform-field-label' for='input_2_4'><span class='gform-field-label__text'>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_4'\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_4'\n\t\t\t\t\tvalue='10\/25\/2026'\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\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_2_4' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_2_4' 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_4' aria-label='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><div id=\"field_2_2\" 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\" data-group-id=\"80a6485b\" data-field-span=\"5\"><label id='gfield_label_2_2' class='gfield_label gform-field-label' for='input_2_2'><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_2' id='input_2_2' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"80a6485b\" data-field-span=\"4\"><label id='gfield_label_2_15' class='gfield_label gform-field-label' for='input_2_15'><span class='gform-field-label__text'>Telephone Number<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_2_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"f7ffa605\" data-field-span=\"6\"><label id='gfield_label_2_3' class='gfield_label gform-field-label' for='input_2_3'><span class='gform-field-label__text'>Pet 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_3' id='input_2_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"f7ffa605\" data-field-span=\"3\"><label id='gfield_label_2_5' class='gfield_label gform-field-label' for='input_2_5'><span class='gform-field-label__text'>Age<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_2_5' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"f7ffa605\" data-field-span=\"3\"><label id='gfield_label_2_6' class='gfield_label gform-field-label' for='input_2_6'><span class='gform-field-label__text'>Weight<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_2_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_7\" 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\" data-group-id=\"463de42d\" data-field-span=\"12\"><label id='gfield_label_2_7' class='gfield_label gform-field-label' for='input_2_7'><span class='gform-field-label__text'>Procedure(s) to be performed<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_7' id='input_2_7' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_9\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"2bfb723b\" data-field-span=\"12\">The clinic must have verification of your pet\u2019s vaccination status.<\/div><div id=\"field_2_8\" 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\" data-group-id=\"7a39a225\" data-field-span=\"12\"><label id='gfield_label_2_8' class='gfield_label gform-field-label' for='input_2_8'><span class='gform-field-label__text'>If your pet\u2019s records are not already with our clinic, where may we obtain them?<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_2_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_10\" 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\" data-group-id=\"8d874c10\" data-field-span=\"12\">If your pet is found to have transmissible conditions such as fleas, ticks, ear mites, or fungal infections, the clinic must treat\nsuch conditions to prevent spread to other patients. Admission of your pet to the hospital constitutes permission for\ntreatment of such transmissible conditions and acceptance of financial responsibility for such treatment.<\/div><fieldset id=\"field_2_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-horizontal\" data-group-id=\"d27fae14\" data-field-span=\"12\"><legend id='gfield_label_2_33' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Do you have any questions or concerns to discuss with the medical staff?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_33'>\n\t\t\t<div class='gchoice gchoice_2_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Yes'  id='choice_2_33_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_2_33_0 gfield_label_2_33\"   \/>\n\t\t\t\t\t<label for='choice_2_33_0' id='label_2_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_2_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_2_33_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_2_33_1' id='label_2_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_12\" 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\" data-group-id=\"4d9c7eac\" data-field-span=\"12\"><label id='gfield_label_2_12' class='gfield_label gform-field-label' for='input_2_12'><span class='gform-field-label__text'>Questions or Concerns<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_2_12' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_13\" 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\" data-group-id=\"bf7fd839\" data-field-span=\"12\">I give my consent and accept financial responsibility for the above-listed procedure(s). Even though animals are given a preprocedure\nexam, 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,\nsurgery, and recovery.<\/div><fieldset id=\"field_2_14\" 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-horizontal\" data-group-id=\"9e698bfa\" data-field-span=\"12\"><legend id='gfield_label_2_14' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>My method of payment today will be:<\/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_14'>\n\t\t\t<div class='gchoice gchoice_2_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Check'  id='choice_2_14_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_2_14_0 gfield_label_2_14\"   \/>\n\t\t\t\t\t<label for='choice_2_14_0' id='label_2_14_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_2_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Credit or Debit Card'  id='choice_2_14_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_2_14_1' id='label_2_14_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_2_14_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Cash'  id='choice_2_14_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_2_14_2' id='label_2_14_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_2_14_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Existing Care Credit Account'  id='choice_2_14_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_2_14_3' id='label_2_14_3' class='gform-field-label gform-field-label--type-inline'>Existing Care Credit Account<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_16\" 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\" data-group-id=\"f0fdd437\" data-field-span=\"12\"><legend id='gfield_label_2_16' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Signature<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_signature\"><input type='hidden' value='' name='input_16' id='input_2_16_signature_filename' class='gfield_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_2_16_Container' class='gfield_signature_container' style='height:90px; width:640px; ' ><input type='hidden' id='input_2_16_data' name='input_2_16_data' class='gfield_signature_data' \/><canvas id=\"input_2_16\" width=\"640\" height=\"90\" style=\"border-style: Dashed; border-width: 2px; border-color: #757575; background-color:#FFFFFF; cursor: url(https:\/\/animalclinicww.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;\" tabindex=\"0\" aria-label=\"Signature pad\" ><\/canvas><input type='text' id='input_2_16_textinput' name='input_2_16_textinput' class='gfield_signature_text_input' style='text-indent:10px;display:none;width:640px;height:90px;border-style:Dashed;border-width:2px;border-color:#757575;background-color:#FFFFFF;font-family:&quot;Snell Roundhand&quot;, &quot;Segoe Script&quot;, cursive;font-size:2em;padding:0 12px;box-sizing:border-box;color:#000000;' placeholder='Type your signature' autocomplete='off' aria-label='Type your signature' \/><style type='text\/css'>\n                #input_2_16_textinput::placeholder {\n                    font-size: 1.5rem;\n                    font-family: Arial;\n                    opacity: 0.8;\n                }\n            <\/style><\/div><div id='input_2_16_toolbar' class='gfield_signature_toolbar' dir='ltr' style='margin:5px 0;position:relative;height:35px;width:640px;max-width:100%;display:flex;align-items:center;'><div id='input_2_16_status' class='gfield_signature_status gform-visually-hidden' role='status' aria-live='polite' aria-atomic='true' style='position:absolute;width:1px;height:1px;padding:0;margin:-1px;overflow:hidden;clip:rect(0,0,0,0);white-space:nowrap;border:0;'><\/div><input type='hidden' id='input_2_16_font_select' class='gfield_signature_font_select' value='script' \/><div id='input_2_16_font_dropdown' class='gfield_signature_font_dropdown'><span class='gform-common-icon gform-common-icon--chevron-down gfield_signature_font_dropdown_icon'><\/span><button type='button' id='input_2_16_font_select_button' class='gfield_signature_font_select_button gform-theme__disable' tabindex='0' aria-haspopup='listbox' aria-expanded='false' aria-label='Font Options' style='width:100%;box-sizing:border-box;overflow:hidden;text-overflow:ellipsis;white-space:nowrap;font-family:\"Snell Roundhand\", \"Segoe Script\", cursive;color:#000000'>Your Name<\/button><ul id='input_2_16_font_select_list' class='gfield_signature_font_select_list' role='listbox' tabindex='-1' style='display:none;position:absolute;top:100%;left:0;right:0;margin:0;padding:0;list-style:none;background:#fff;border:1px solid #ccc;z-index:10;max-height:200px;overflow-y:auto;box-sizing:border-box;'><li class='gfield_signature_font_option' role='option' data-value='script' tabindex='0' style='font-family:&quot;Snell Roundhand&quot;, &quot;Segoe Script&quot;, cursive; color:#000000' aria-label='Your Name, Script style'>Your Name<\/li><li class='gfield_signature_font_option' role='option' data-value='handwritten' tabindex='0' style='font-family:&quot;Bradley Hand&quot;, &quot;Comic Sans MS&quot;, cursive; color:#000000' aria-label='Your Name, Handwritten style'>Your Name<\/li><li class='gfield_signature_font_option' role='option' data-value='print' tabindex='0' style='font-family:&quot;Noteworthy&quot;, &quot;Segoe Print&quot;, cursive; color:#000000' aria-label='Your Name, Print style'>Your Name<\/li><\/ul><\/div><div class='gfield_signature_toolbar_icons' style='margin-left:auto;display:flex;align-items:center;'><button type='button' id='input_2_16_textbutton' class='gform-common-icon gform-common-icon--text-field gfield_signature_text_button gform-theme-no-framework' tabindex='0' style='background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer;' alt='Text Signature' aria-label='Text Signature'><\/button><button type='button' id='input_2_16_drawbutton' class='gform-common-icon gform-common-icon--pencil gfield_signature_draw_button gform-theme-no-framework' tabindex='0' style='display:none;background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer;' alt='Draw Signature' aria-label='Draw Signature'><\/button><button type='button' id='input_2_16_resetbutton' class='gform-common-icon gform-common-icon--arrow-path gfield_signature_reset_button gform-theme-no-framework' tabindex='0' style='background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer;' alt='Clear Signature' aria-label='Clear Signature'><\/button><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_2_17\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"55be2c16\" data-field-span=\"12\"><h3 class=\"gsection_title\">TO BE COMPLETED BY HOSPITAL STAFF:<\/h3><\/div><fieldset id=\"field_2_18\" 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-horizontal\" data-group-id=\"8216b5e9\" data-field-span=\"12\"><legend id='gfield_label_2_18' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Has your pet eaten today?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_18'>\n\t\t\t<div class='gchoice gchoice_2_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Yes'  id='choice_2_18_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_2_18_0 gfield_label_2_18\"   \/>\n\t\t\t\t\t<label for='choice_2_18_0' id='label_2_18_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_2_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='No'  id='choice_2_18_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_2_18_1' id='label_2_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_19\" 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-horizontal\" data-group-id=\"b7046e33\" data-field-span=\"12\"><legend id='gfield_label_2_19' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Have you noticed any vomiting, diarrhea, and\/or coughing during the past 7 days?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_19'>\n\t\t\t<div class='gchoice gchoice_2_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_2_19_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_2_19_0 gfield_label_2_19\"   \/>\n\t\t\t\t\t<label for='choice_2_19_0' id='label_2_19_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_2_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_2_19_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_2_19_1' id='label_2_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_20\" 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-horizontal\" data-group-id=\"25f3b348\" data-field-span=\"12\"><legend id='gfield_label_2_20' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Is your pet on any medication?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_20'>\n\t\t\t<div class='gchoice gchoice_2_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Yes'  id='choice_2_20_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_2_20_0 gfield_label_2_20\"   \/>\n\t\t\t\t\t<label for='choice_2_20_0' id='label_2_20_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_2_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='No'  id='choice_2_20_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_2_20_1' id='label_2_20_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_22\" 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\" data-group-id=\"1301d884\" data-field-span=\"12\"><label id='gfield_label_2_22' class='gfield_label gform-field-label' for='input_2_22'><span class='gform-field-label__text'>What type and how often?<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_2_22' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_24\" 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\" data-group-id=\"82110dbb\" data-field-span=\"12\"><label id='gfield_label_2_24' class='gfield_label gform-field-label' for='input_2_24'><span class='gform-field-label__text'>What time did your pet have medication today?<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_2_24' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_2_23\" 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-horizontal\" data-group-id=\"4d50a81d\" data-field-span=\"12\"><legend id='gfield_label_2_23' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Does your pet have a history of allergic reactions to any medications?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_23'>\n\t\t\t<div class='gchoice gchoice_2_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_2_23_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_2_23_0 gfield_label_2_23\"   \/>\n\t\t\t\t\t<label for='choice_2_23_0' id='label_2_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_2_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_2_23_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_2_23_1' id='label_2_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_23_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Unknown'  id='choice_2_23_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_2_23_2' id='label_2_23_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_25\" 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-horizontal\" data-group-id=\"9f56cbb4\" data-field-span=\"12\"><legend id='gfield_label_2_25' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Has your pet been anesthetized in the past?<\/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='Yes'  id='choice_2_25_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_2_25_0 gfield_label_2_25\"   \/>\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'>Yes<\/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='No'  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'>No<\/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='Unknown'  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'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_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-horizontal\" data-group-id=\"bff19dfa\" data-field-span=\"12\"><legend id='gfield_label_2_26' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Did your pet have any complications during or following the anesthesia?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_26'>\n\t\t\t<div class='gchoice gchoice_2_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_2_26_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_2_26_0 gfield_label_2_26\"   \/>\n\t\t\t\t\t<label for='choice_2_26_0' id='label_2_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_2_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_2_26_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_2_26_1' id='label_2_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_26_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Unknown'  id='choice_2_26_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_2_26_2' id='label_2_26_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_27\" 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\" data-group-id=\"b1f9a177\" data-field-span=\"12\"><label id='gfield_label_2_27' class='gfield_label gform-field-label' for='input_2_27'><span class='gform-field-label__text'>Describe:<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_27' id='input_2_27' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_2_28\" 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-horizontal\" data-group-id=\"64a03287\" data-field-span=\"12\"><legend id='gfield_label_2_28' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>May we perform pre-anesthesia bloodwork today?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_28'>\n\t\t\t<div class='gchoice gchoice_2_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Already Completed\/Required'  id='choice_2_28_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_2_28_0 gfield_label_2_28\"   \/>\n\t\t\t\t\t<label for='choice_2_28_0' id='label_2_28_0' class='gform-field-label gform-field-label--type-inline'>Already Completed\/Required<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Elect'  id='choice_2_28_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_2_28_1' id='label_2_28_1' class='gform-field-label gform-field-label--type-inline'>Elect<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_28_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Decline'  id='choice_2_28_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_2_28_2' id='label_2_28_2' class='gform-field-label gform-field-label--type-inline'>Decline<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_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-horizontal\" data-group-id=\"347f782e\" data-field-span=\"12\"><legend id='gfield_label_2_29' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>May we administer peri-operative fluids?<\/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='Required'  id='choice_2_29_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_2_29_0 gfield_label_2_29\"   \/>\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'>Required<\/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='Elect'  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'>Elect<\/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='Decline'  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'>Decline<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_30\" 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-horizontal\" data-group-id=\"b14254a0\" data-field-span=\"12\"><legend id='gfield_label_2_30' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>May we administer peri-operative fluids?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_30'>\n\t\t\t<div class='gchoice gchoice_2_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Required'  id='choice_2_30_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_2_30_0 gfield_label_2_30\"   \/>\n\t\t\t\t\t<label for='choice_2_30_0' id='label_2_30_0' class='gform-field-label gform-field-label--type-inline'>Required<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Elect'  id='choice_2_30_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_2_30_1' id='label_2_30_1' class='gform-field-label gform-field-label--type-inline'>Elect<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_30_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Decline'  id='choice_2_30_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_2_30_2' id='label_2_30_2' class='gform-field-label gform-field-label--type-inline'>Decline<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_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-horizontal\" data-group-id=\"d0d92f47\" data-field-span=\"12\"><legend id='gfield_label_2_31' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Would you like to have your pet Microchipped ?<\/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='Elect'  id='choice_2_31_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_2_31_0 gfield_label_2_31\"   \/>\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'>Elect<\/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='Decline'  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'>Decline<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_32\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"6932a935\" data-field-span=\"12\"><legend id='gfield_label_2_32' 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