{"id":347,"date":"2020-12-10T14:03:24","date_gmt":"2020-12-10T19:03:24","guid":{"rendered":"https:\/\/www.shoemakervet.com\/?page_id=347"},"modified":"2020-12-10T14:04:50","modified_gmt":"2020-12-10T19:04:50","slug":"consent-form","status":"publish","type":"page","link":"https:\/\/www.shoemakervet.com\/consent-form\/","title":{"rendered":"Consent Form"},"content":{"rendered":"<script type=\"text\/javascript\">var 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9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg version='1.1' xmlns='http:\/\/www.w3.org\/2000\/svg' width='640' height='640'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 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-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_3' id='gform_3'  action='\/wp-json\/wp\/v2\/pages\/347#gf_3' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_7\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_7\" ><h2 class=\"gsection_title\">Client Information<\/h2><\/li><li id=\"field_3_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_1\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Client&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_1'>\n                            \n                            <span id='input_3_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_3_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_3_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_3_30\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_30\" ><label class='gfield_label gform-field-label' for='input_3_30'>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_30' id='input_3_30' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_3_31\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_31\" ><label class='gfield_label gform-field-label' for='input_3_31'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_31' id='input_3_31' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_32\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_32\" ><label class='gfield_label gform-field-label' for='input_3_32'>Phone number of person bring pet to appointment, if different than above.<\/label><div class='ginput_container ginput_container_phone'><input name='input_32' id='input_3_32' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_10\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_10\" ><label class='gfield_label gform-field-label' for='input_3_10'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_3_10' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_3\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_3\" ><label class='gfield_label gform-field-label' for='input_3_3'>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_3' id='input_3_3' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_4\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_4\" ><label class='gfield_label gform-field-label' for='input_3_4'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_3_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_5\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_5\" ><label class='gfield_label gform-field-label' for='input_3_5'>Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_3_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_35\" ><label class='gfield_label gform-field-label' >Species<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_35'>\n\t\t\t<li class='gchoice gchoice_3_35_0'>\n\t\t\t\t<input name='input_35' type='radio' value='Dog'  id='choice_3_35_0'    \/>\n\t\t\t\t<label for='choice_3_35_0' id='label_3_35_0' class='gform-field-label gform-field-label--type-inline'>Dog<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_35_1'>\n\t\t\t\t<input name='input_35' type='radio' value='Cat'  id='choice_3_35_1'    \/>\n\t\t\t\t<label for='choice_3_35_1' id='label_3_35_1' class='gform-field-label gform-field-label--type-inline'>Cat<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_35_2'>\n\t\t\t\t<input name='input_35' type='radio' value='Other'  id='choice_3_35_2'    \/>\n\t\t\t\t<label for='choice_3_35_2' id='label_3_35_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_6\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_6\" ><label class='gfield_label gform-field-label' for='input_3_6'>Procedure(s)<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_3_6' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_8\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_8\" ><h2 class=\"gsection_title\">Visit Information<\/h2><\/li><li id=\"field_3_33\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_33\" ><label class='gfield_label gform-field-label' for='input_3_33'>Date and time of my pet&#039;s last meal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_3_33' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_11\" ><label class='gfield_label gform-field-label' >Have you administered any medication, supplements, or vitamins to your pet in the last 48 hours?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_11'>\n\t\t\t<li class='gchoice gchoice_3_11_0'>\n\t\t\t\t<input name='input_11' type='radio' value='Yes'  id='choice_3_11_0'    \/>\n\t\t\t\t<label for='choice_3_11_0' id='label_3_11_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_11_1'>\n\t\t\t\t<input name='input_11' type='radio' value='No'  id='choice_3_11_1'    \/>\n\t\t\t\t<label for='choice_3_11_1' id='label_3_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_12\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_12\" ><label class='gfield_label gform-field-label' for='input_3_12'>Which medication(s)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_3_12' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_13\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_13\" ><label class='gfield_label gform-field-label' for='input_3_13'>What dose and strength?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_3_13' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_14\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_14\" ><label class='gfield_label gform-field-label' for='input_3_14'>When was the medication given?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_3_14' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_15\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_15\" ><label class='gfield_label gform-field-label' for='input_3_15'>How many tablets, capsules, or ccs were administered?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_3_15' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_26\" ><label class='gfield_label gform-field-label' >Do you use flea and tick prevention on your pet?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_26'>\n\t\t\t<li class='gchoice gchoice_3_26_0'>\n\t\t\t\t<input name='input_26' type='radio' value='Yes'  id='choice_3_26_0'    \/>\n\t\t\t\t<label for='choice_3_26_0' id='label_3_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_26_1'>\n\t\t\t\t<input name='input_26' type='radio' value='No'  id='choice_3_26_1'    \/>\n\t\t\t\t<label for='choice_3_26_1' id='label_3_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_27\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_27\" ><label class='gfield_label gform-field-label' for='input_3_27'>What type and when was it administered?<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_3_27' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_28\" ><label class='gfield_label gform-field-label' >Do you administer heartworm prevention to your pet?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_28'>\n\t\t\t<li class='gchoice gchoice_3_28_0'>\n\t\t\t\t<input name='input_28' type='radio' value='Yes'  id='choice_3_28_0'    \/>\n\t\t\t\t<label for='choice_3_28_0' id='label_3_28_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_28_1'>\n\t\t\t\t<input name='input_28' type='radio' value='No'  id='choice_3_28_1'    \/>\n\t\t\t\t<label for='choice_3_28_1' id='label_3_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_29\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_29\" ><label class='gfield_label gform-field-label' for='input_3_29'>What type and when was it administered?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_3_29' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_16\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >I would like to add the following elective procedures to my pet&#039;s visit<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_16'><li class='gchoice gchoice_3_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Nail Trim ($20.00-$45.00 | No charge if pet is under anesthesia)'  id='choice_3_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_16_1' id='label_3_16_1' class='gform-field-label gform-field-label--type-inline'>Nail Trim ($20.00-$45.00 | No charge if pet is under anesthesia)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Anal Gland Expression ($20.00)'  id='choice_3_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_16_2' id='label_3_16_2' class='gform-field-label gform-field-label--type-inline'>Anal Gland Expression ($20.00)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Microchip Implantation ($40.00)'  id='choice_3_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_16_3' id='label_3_16_3' class='gform-field-label gform-field-label--type-inline'>Microchip Implantation ($40.00)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='Ear Cleaning ($15.00)'  id='choice_3_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_16_4' id='label_3_16_4' class='gform-field-label gform-field-label--type-inline'>Ear Cleaning ($15.00)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_16_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.5' type='checkbox'  value='4DX Snap Test ($59.00)'  id='choice_3_16_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_16_5' id='label_3_16_5' class='gform-field-label gform-field-label--type-inline'>4DX Snap Test ($59.00)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_16_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.6' type='checkbox'  value='Feline Aids\/Leukemia Test ($55.00)'  id='choice_3_16_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_16_6' id='label_3_16_6' class='gform-field-label gform-field-label--type-inline'>Feline Aids\/Leukemia Test ($55.00)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_16_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.7' type='checkbox'  value='Vaccines (if due)'  id='choice_3_16_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_16_7' id='label_3_16_7' class='gform-field-label gform-field-label--type-inline'>Vaccines (if due)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_16_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.8' type='checkbox'  value='Other'  id='choice_3_16_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_16_8' id='label_3_16_8' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_16_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.9' type='checkbox'  value='None'  id='choice_3_16_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_16_9' id='label_3_16_9' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_17\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_17\" ><label class='gfield_label gform-field-label' for='input_3_17'>Other<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_3_17' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_22\" ><label class='gfield_label gform-field-label' >Pre-Anesthetic Diagnostics<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_22'>\n\t\t\t<li class='gchoice gchoice_3_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='My pet has already had pre-anesthetic blood work'  id='choice_3_22_0'    \/>\n\t\t\t\t<label for='choice_3_22_0' id='label_3_22_0' class='gform-field-label gform-field-label--type-inline'>My pet has already had pre-anesthetic blood work<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='My pet has already had pre-anesthetic x-rays'  id='choice_3_22_1'    \/>\n\t\t\t\t<label for='choice_3_22_1' id='label_3_22_1' class='gform-field-label gform-field-label--type-inline'>My pet has already had pre-anesthetic x-rays<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_22_2'>\n\t\t\t\t<input name='input_22' type='radio' value='I approve pre-anesthetic blood work'  id='choice_3_22_2'    \/>\n\t\t\t\t<label for='choice_3_22_2' id='label_3_22_2' class='gform-field-label gform-field-label--type-inline'>I approve pre-anesthetic blood work<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_22_3'>\n\t\t\t\t<input name='input_22' type='radio' value='I approve pre-anesthetic x-rays'  id='choice_3_22_3'    \/>\n\t\t\t\t<label for='choice_3_22_3' id='label_3_22_3' class='gform-field-label gform-field-label--type-inline'>I approve pre-anesthetic x-rays<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_22_4'>\n\t\t\t\t<input name='input_22' type='radio' value='I decline'  id='choice_3_22_4'    \/>\n\t\t\t\t<label for='choice_3_22_4' id='label_3_22_4' class='gform-field-label gform-field-label--type-inline'>I decline<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_22_5'>\n\t\t\t\t<input name='input_22' type='radio' value='Not Applicable'  id='choice_3_22_5'    \/>\n\t\t\t\t<label for='choice_3_22_5' id='label_3_22_5' class='gform-field-label gform-field-label--type-inline'>Not Applicable<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_23\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_23\" ><h2 class=\"gsection_title\">Baby Teeth Extraction<\/h2><\/li><li id=\"field_3_24\" 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\"  data-js-reload=\"field_3_24\" ><p>\nSmall breed pets often suffer from retained deciduous (baby) teeth after their adult teeth grow in. This condition creates overcrowding of teeth, retention of food or other debris between the teeth, and tartar buildup. This, in turn, leads to bad breath and damage to gums and adult teeth. We strongly recommend that these deciduous teeth be extracted while your pet is under anesthesia to avoid future complications. The cost for this procedure varies based the number of teeth extracted. \n<\/p><\/li><li id=\"field_3_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_25\" ><label class='gfield_label gform-field-label' >I approve my pet&#039;s baby teeth to be extracted if present<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_25'>\n\t\t\t<li class='gchoice gchoice_3_25_0'>\n\t\t\t\t<input name='input_25' type='radio' value='Yes'  id='choice_3_25_0'    \/>\n\t\t\t\t<label for='choice_3_25_0' id='label_3_25_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_25_1'>\n\t\t\t\t<input name='input_25' type='radio' value='No'  id='choice_3_25_1'    \/>\n\t\t\t\t<label for='choice_3_25_1' id='label_3_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_25_2'>\n\t\t\t\t<input name='input_25' type='radio' value='Not Applicable'  id='choice_3_25_2'    \/>\n\t\t\t\t<label for='choice_3_25_2' id='label_3_25_2' class='gform-field-label gform-field-label--type-inline'>Not Applicable<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_18\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_18\" ><h2 class=\"gsection_title\">Consent<\/h2><\/li><li id=\"field_3_19\" 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\"  data-js-reload=\"field_3_19\" ><p>I certify that I am the owner, or authorized agent for the owner, of the above animal. l hereby consent to and authorize the doctors and staff at this veterinary practice to admit this pet, perform the above described procedures, and administer medications, anesthesia, surgical procedures, tests and\/or treatments that the doctors deem necessary for its health, safety and well being while under their care and supervision. I have been advised of the nature of the procedures and the potential risks and benefits. I understand that veterinary medicine is an inexact science and that no guarantee of successful treatment can be made.<\/p>\n\n<p><strong>Photograph Release:<\/strong>\nI hereby grant Shoemaker Avenue Animal Hospital permission to take photographs of my pet and to publish those photographs for any lawful purpose, including but not limited to their website, social media accounts and promotional materials, either digital or in print, in perpetuity. I also grant permission to use my name and\/or my pet&#8217;s name. By signing and dating this document I authorize Shoemaker Avenue Animal Hospital to edit, alter, share, remix, tweak, build upon or in any way alter the photograph(s) mentioned above. I also waive any rights of privacy or compensation associated with the use of my pet&#8217;s image(s) and name(s) for personal, educational or commercial purposes outlined above.<\/p>\n \n<p>I acknowledge that I am responsible for payment in full for the above procedures and treatments at the time my pet is discharged.<\/p><\/li><li id=\"field_3_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_34\" ><label class='gfield_label gform-field-label' >CPR in the event of cardiac arrest.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_34'>\n\t\t\t<li class='gchoice gchoice_3_34_0'>\n\t\t\t\t<input name='input_34' type='radio' value='In the event of cardiac arrest, I elect to have CPR performed on my pet. I understand this may result in additional charges up to or beyond $300.'  id='choice_3_34_0'    \/>\n\t\t\t\t<label for='choice_3_34_0' id='label_3_34_0' class='gform-field-label gform-field-label--type-inline'>In the event of cardiac arrest, I elect to have CPR performed on my pet. I understand this may result in additional charges up to or beyond $300.<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_34_1'>\n\t\t\t\t<input name='input_34' type='radio' value='In the event of cardiac arrest, I DO NOT want CPR performed on my pet.'  id='choice_3_34_1'    \/>\n\t\t\t\t<label for='choice_3_34_1' id='label_3_34_1' class='gform-field-label gform-field-label--type-inline'>In the event of cardiac arrest, I DO NOT want CPR performed on my pet.<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_21\" class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_21\" ><label class='gfield_label gform-field-label' for='input_3_21'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_21_Container' class='gfield_signature_container ginput_container' style='height:180px; 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