{"id":3060,"date":"2020-08-07T18:36:50","date_gmt":"2020-08-07T23:36:50","guid":{"rendered":"http:\/\/avgvet.wpengine.com\/?page_id=3060"},"modified":"2020-09-30T19:19:48","modified_gmt":"2020-09-30T19:19:48","slug":"forms","status":"publish","type":"page","link":"https:\/\/www.riversidevethospital.com\/pet-resources\/forms\/","title":{"rendered":"Forms"},"content":{"rendered":"<div class=\"wpb-content-wrapper\">[vc_row][vc_column][vc_column_text]Riverside Animal Hospital offers our patient form(s) online so you can complete it in the convenience of your own home or office.<\/p>\n<p>This page is to better serve our clients and save time when checking in. Attached you will find the necessary forms for your visit to our hospital. It is very important that you take the time to read and complete the entire form(s). If this will be your first visit to Riverside Animal Hospital we welcome you and ask that you complete the &#8220;Client Information Form&#8221;. Please make sure to bring along all previous records for your pet. This will ensure that we have a history on the patient and that all vaccinations are current.<\/p>\n<h3>Forms<\/h3>\n<p>[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_tta_tabs][vc_tta_section title=&#8221;New Client Pet Information Sheet&#8221; tab_id=&#8221;1601413631070-9d01c1bd-5fd9&#8243;]<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script><\/p>\n<div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_5' style='display:none'>\n<div id='gf_5' class='gform_anchor' tabindex='-1'><\/div>\n<div class='gform_heading'>\n<h3 class=\"gform_title\">New Client Pet Information Sheet<\/h3>\n<p class='gform_description'>\n<\/p><\/div>\n<form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_5' id='gform_5'  action='\/wp-json\/wp\/v2\/pages\/3060\/#gf_5' data-formid='5' novalidate>\n<div class='gf_invisible ginput_recaptchav3' data-sitekey='6LdZfxInAAAAAGDhjfmQg7QmhadVqjI6NyDa8c0_' data-tabindex='0'><input id=\"input_0ccb4d249aa69678abf7b34cbc036139\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_0ccb4d249aa69678abf7b34cbc036139\" value=\"\"\/><\/div>\n<div class='gform-body gform_body'>\n<ul id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'>\n<li id=\"field_5_1\" 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_5_1\" >\n<h3>Owner's Name<\/h3>\n<\/li>\n<li id=\"field_5_13\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_13\" ><label class='gfield_label gform-field-label' for='input_5_13'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>\n<div class='ginput_container ginput_container_text'><input name='input_13' id='input_5_13' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_2\" class=\"gfield gfield--type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_2\" ><label class='gfield_label gform-field-label' for='input_5_2'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>\n<div class='ginput_container ginput_container_text'><input name='input_2' id='input_5_2' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_3\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_3\" ><label class='gfield_label gform-field-label' for='input_5_3'>Middle Initial<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_3' id='input_5_3' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_4\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_4\" ><label class='gfield_label gform-field-label' for='input_5_4'>Spouse&#039;s First Name<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_4' id='input_5_4' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_5\" 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_5_5\" >\n<h3>Address<\/h3>\n<\/li>\n<li id=\"field_5_6\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_6\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>\n<div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_6' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_6_1_container' ><br \/>\n                                        <input type='text' name='input_6.1' id='input_5_6_1' value=''    aria-required='true'    \/><br \/>\n                                        <label for='input_5_6_1' id='input_5_6_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label><br \/>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_6_2_container' ><br \/>\n                                        <input type='text' name='input_6.2' id='input_5_6_2' value=''     aria-required='false'   \/><br \/>\n                                        <label for='input_5_6_2' id='input_5_6_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label><br \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_6_3_container' ><br \/>\n                                    <input type='text' name='input_6.3' id='input_5_6_3' value=''    aria-required='true'    \/><br \/>\n                                    <label for='input_5_6_3' id='input_5_6_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label><br \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_6_4_container' ><br \/>\n                                        <select name='input_6.4' id='input_5_6_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select><br \/>\n                                        <label for='input_5_6_4' id='input_5_6_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label><br \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_6_5_container' ><br \/>\n                                    <input type='text' name='input_6.5' id='input_5_6_5' value=''    aria-required='true'    \/><br \/>\n                                    <label for='input_5_6_5' id='input_5_6_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label><br \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_6.6' id='input_5_6_6' value='United States' \/><\/p>\n<div class='gf_clear gf_clear_complex'><\/div>\n<\/p><\/div>\n<\/li>\n<li id=\"field_5_14\" 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_5_14\" >\n<h3>Phone Numbers<\/h3>\n<\/li>\n<li id=\"field_5_15\" class=\"gfield gfield--type-phone gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_15\" ><label class='gfield_label gform-field-label' for='input_5_15'>Home Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>\n<div class='ginput_container ginput_container_phone'><input name='input_15' id='input_5_15' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div>\n<\/li>\n<li id=\"field_5_16\" class=\"gfield gfield--type-phone gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_16\" ><label class='gfield_label gform-field-label' for='input_5_16'>Work Phone<\/label>\n<div class='ginput_container ginput_container_phone'><input name='input_16' id='input_5_16' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div>\n<\/li>\n<li id=\"field_5_17\" class=\"gfield gfield--type-phone gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_17\" ><label class='gfield_label gform-field-label' for='input_5_17'>Spouse&#039;s Phone<\/label>\n<div class='ginput_container ginput_container_phone'><input name='input_17' id='input_5_17' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div>\n<\/li>\n<li id=\"field_5_58\" 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_5_58\" ><label class='gfield_label gform-field-label' for='input_5_58'>Cell Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>\n<div class='ginput_container ginput_container_phone'><input name='input_58' id='input_5_58' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div>\n<\/li>\n<li id=\"field_5_7\" 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_5_7\" >\n<h3>Email Address<\/h3>\n<\/li>\n<li id=\"field_5_8\" 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_5_8\" ><label class='gfield_label gform-field-label' for='input_5_8'>please enter your email address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>\n<div class='ginput_container ginput_container_email'>\n                            <input name='input_8' id='input_5_8' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div>\n<\/li>\n<li id=\"field_5_9\" 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_5_9\" >\n<h3>Referred By<\/h3>\n<\/li>\n<li id=\"field_5_10\" class=\"gfield gfield--type-multiselect gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_10\" ><label class='gfield_label gform-field-label' for='input_5_10'>Referred By<\/label>\n<div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_10[]' id='input_5_10' class='large gfield_select'   aria-invalid=\"false\"  ><option value='Friend' >Friend<\/option><option value='Company' >Company<\/option><option value='Yellow Pages' >Yellow Pages<\/option><option value='Hospital SIgn' >Hospital SIgn<\/option><option value='News Paper' >News Paper<\/option><option value='Client' >Client<\/option><option value='Website' >Website<\/option><option value='Veterinarian' >Veterinarian<\/option><option value='Email from someone' >Email from someone<\/option><\/select><\/div>\n<\/li>\n<li id=\"field_5_12\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_12\" ><label class='gfield_label gform-field-label' for='input_5_12'>Please Explain...<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_12' id='input_5_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_18\" 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_5_18\" >\n<h3>Identification<\/h3>\n<\/li>\n<li id=\"field_5_19\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_19\" ><label class='gfield_label gform-field-label' for='input_5_19'>Driver&#039;s License Number<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_19' id='input_5_19' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_20\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_20\" ><label class='gfield_label gform-field-label' for='input_5_20'>State<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_20' id='input_5_20' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_21\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_21\" ><label class='gfield_label gform-field-label' for='input_5_21'>Date of Birth<\/label>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_21' id='input_5_21' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_21_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_5_21_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_5_21' class='gform_hidden' value='https:\/\/www.riversidevethospital.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li>\n<li id=\"field_5_22\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_22\" ><label class='gfield_label gform-field-label' for='input_5_22'>Social Security Number<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_22' id='input_5_22' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_23\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_23\" ><label class='gfield_label gform-field-label' for='input_5_23'>Name of Employer<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_23' id='input_5_23' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_24\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_24\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address of Employer<\/label>\n<div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_5_24' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_24_1_container' ><br \/>\n                                        <input type='text' name='input_24.1' id='input_5_24_1' value=''    aria-required='false'    \/><br \/>\n                                        <label for='input_5_24_1' id='input_5_24_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label><br \/>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_24_2_container' ><br \/>\n                                        <input type='text' name='input_24.2' id='input_5_24_2' value=''     aria-required='false'   \/><br \/>\n                                        <label for='input_5_24_2' id='input_5_24_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label><br \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_24_3_container' ><br \/>\n                                    <input type='text' name='input_24.3' id='input_5_24_3' value=''    aria-required='false'    \/><br \/>\n                                    <label for='input_5_24_3' id='input_5_24_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label><br \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_24_4_container' ><br \/>\n                                        <input type='text' name='input_24.4' id='input_5_24_4' value=''      aria-required='false'    \/><br \/>\n                                        <label for='input_5_24_4' id='input_5_24_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label><br \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_24_5_container' ><br \/>\n                                    <input type='text' name='input_24.5' id='input_5_24_5' value=''    aria-required='false'    \/><br \/>\n                                    <label for='input_5_24_5' id='input_5_24_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label><br \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_5_24_6_container' ><br \/>\n                                        <select name='input_24.6' id='input_5_24_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select><br \/>\n                                        <label for='input_5_24_6' id='input_5_24_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label><br \/>\n                                    <\/span><\/p>\n<div class='gf_clear gf_clear_complex'><\/div>\n<\/p><\/div>\n<\/li>\n<li id=\"field_5_25\" 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_5_25\" >\n<h3>Your Pet (1)<\/h3>\n<\/li>\n<li id=\"field_5_26\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_26\" ><label class='gfield_label gform-field-label' for='input_5_26'>Pet&#039;s Name<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_26' id='input_5_26' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_27\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_27\" ><label class='gfield_label gform-field-label' for='input_5_27'>Breed<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_27' id='input_5_27' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_28\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_28\" ><label class='gfield_label gform-field-label' for='input_5_28'>Color<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_28' id='input_5_28' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_29\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_29\" ><label class='gfield_label gform-field-label' for='input_5_29'>Species<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_29' id='input_5_29' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_30\" class=\"gfield gfield--type-select gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_30\" ><label class='gfield_label gform-field-label' for='input_5_30'>Sex<\/label>\n<div class='ginput_container ginput_container_select'><select name='input_30' id='input_5_30' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><option value='Altered' >Altered<\/option><\/select><\/div>\n<\/li>\n<li id=\"field_5_31\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_31\" ><label class='gfield_label gform-field-label' for='input_5_31'>Birthdate<\/label>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_31' id='input_5_31' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_31_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_5_31_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_5_31' class='gform_hidden' value='https:\/\/www.riversidevethospital.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li>\n<li id=\"field_5_32\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_32\" ><label class='gfield_label gform-field-label' for='input_5_32'>Vaccination\/Booster Shot Date<\/label>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_32' id='input_5_32' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_32_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_5_32_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_5_32' class='gform_hidden' value='https:\/\/www.riversidevethospital.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li>\n<li id=\"field_5_33\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_33\" ><label class='gfield_label gform-field-label' for='input_5_33'>Rabies<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_33' id='input_5_33' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_34\" 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_5_34\" >\n<h3>Your Pet (2)<\/h3>\n<\/li>\n<li id=\"field_5_35\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_35\" ><label class='gfield_label gform-field-label' for='input_5_35'>Pet&#039;s Name<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_35' id='input_5_35' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_36\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_36\" ><label class='gfield_label gform-field-label' for='input_5_36'>Breed<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_36' id='input_5_36' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_37\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_37\" ><label class='gfield_label gform-field-label' for='input_5_37'>Color<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_37' id='input_5_37' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_38\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_38\" ><label class='gfield_label gform-field-label' for='input_5_38'>Species<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_38' id='input_5_38' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_39\" class=\"gfield gfield--type-select gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_39\" ><label class='gfield_label gform-field-label' for='input_5_39'>Sex<\/label>\n<div class='ginput_container ginput_container_select'><select name='input_39' id='input_5_39' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><option value='Altered' >Altered<\/option><\/select><\/div>\n<\/li>\n<li id=\"field_5_40\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_40\" ><label class='gfield_label gform-field-label' for='input_5_40'>Birthdate<\/label>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_40' id='input_5_40' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_40_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_5_40_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_5_40' class='gform_hidden' value='https:\/\/www.riversidevethospital.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li>\n<li id=\"field_5_41\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_41\" ><label class='gfield_label gform-field-label' for='input_5_41'>Vaccination\/Booster Shot Date<\/label>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_41' id='input_5_41' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_41_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_5_41_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_5_41' class='gform_hidden' value='https:\/\/www.riversidevethospital.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li>\n<li id=\"field_5_42\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_42\" ><label class='gfield_label gform-field-label' for='input_5_42'>Rabies<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_42' id='input_5_42' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_43\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_43\" >\n<h3>Your Pet (3)<\/h3>\n<\/li>\n<li id=\"field_5_44\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_44\" ><label class='gfield_label gform-field-label' for='input_5_44'>Pet&#039;s Name<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_44' id='input_5_44' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_45\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_45\" ><label class='gfield_label gform-field-label' for='input_5_45'>Breed<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_45' id='input_5_45' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_46\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_46\" ><label class='gfield_label gform-field-label' for='input_5_46'>Color<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_46' id='input_5_46' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_47\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_47\" ><label class='gfield_label gform-field-label' for='input_5_47'>Species<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_47' id='input_5_47' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_48\" class=\"gfield gfield--type-select gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_48\" ><label class='gfield_label gform-field-label' for='input_5_48'>Sex<\/label>\n<div class='ginput_container ginput_container_select'><select name='input_48' id='input_5_48' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><option value='Altered' >Altered<\/option><\/select><\/div>\n<\/li>\n<li id=\"field_5_49\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_49\" ><label class='gfield_label gform-field-label' for='input_5_49'>Birthdate<\/label>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_49' id='input_5_49' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_49_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_5_49_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_5_49' class='gform_hidden' value='https:\/\/www.riversidevethospital.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li>\n<li id=\"field_5_50\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_50\" ><label class='gfield_label gform-field-label' for='input_5_50'>Vaccination\/Booster Shot Date<\/label>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_50' id='input_5_50' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_50_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_5_50_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_5_50' class='gform_hidden' value='https:\/\/www.riversidevethospital.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li>\n<li id=\"field_5_51\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_51\" ><label class='gfield_label gform-field-label' for='input_5_51'>Rabies<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_51' id='input_5_51' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_52\" 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_5_52\" >\n<h3>Please electronically sign the following authorization for treatment<\/h3>\n<p>I hereby authorize the staff of Riverside Animal Hospital to render any treatment, which is deemed necessary to my pet(s) health while in custody of the hospital. I understand that in the event of any unusual or emergency cirumstances, the staff will make every attempt to contact me or my designated representative before, if time permits, proceeding with treatment. I understand that I will be financially responsible for all emergency procedures including the estimate of charges provided to me in person or over the telephone. <strong>I understand that professional fees are to be paid at time services are rendered and a deposit is required on all pets admitted to the hospital<\/strong>.<\/li>\n<li id=\"field_5_53\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_simple_horizontal gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_53\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Acceptance of the terms above, and that all information submitted through this form is true and correct.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>\n<div class='ginput_container ginput_container_checkbox'>\n<ul class='gfield_checkbox' id='input_5_53'>\n<li class='gchoice gchoice_5_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='I Agree'  id='choice_5_53_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_53_1' id='label_5_53_1' class='gform-field-label gform-field-label--type-inline'>I Agree<\/label>\n\t\t\t\t\t\t\t<\/li>\n<\/ul>\n<\/div>\n<\/li>\n<li id=\"field_5_54\" 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_5_54\" ><label class='gfield_label gform-field-label' for='input_5_54'>Please type your Full Name as electronic signature of Owner, Agent or Good Samaritan<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>\n<div class='ginput_container ginput_container_text'><input name='input_54' id='input_5_54' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_5_55\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_55\" >\n<hr>\n<\/li>\n<li id=\"field_5_57\" 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_5_57\" >\n<h3>Method of Payment<\/h3>\n<\/li>\n<li id=\"field_5_56\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_56\" ><label class='gfield_label gform-field-label' for='input_5_56'>select a payment method<\/label>\n<div class='ginput_container ginput_container_select'><select name='input_56' id='input_5_56' class='large gfield_select'     aria-invalid=\"false\" ><option value='Cash' >Cash<\/option><option value='Check' >Check<\/option><option value='Visa' >Visa<\/option><option value='Mastercard' >Mastercard<\/option><option value='Discover' >Discover<\/option><option value='American Express' >American Express<\/option><\/select><\/div>\n<\/li>\n<\/ul>\n<\/div>\n<div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_5' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_5\"]){return false;}  if( !jQuery(\"#gform_5\")[0].checkValidity || jQuery(\"#gform_5\")[0].checkValidity()){window[\"gf_submitting_5\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_5\"]){return false;} if( !jQuery(\"#gform_5\")[0].checkValidity || jQuery(\"#gform_5\")[0].checkValidity()){window[\"gf_submitting_5\"]=true;}  jQuery(\"#gform_5\").trigger(\"submit\",[true]); }' \/> <input type='hidden' name='gform_ajax' value='form_id=5&amp;title=1&amp;description=1&amp;tabindex=0&amp;theme=legacy' \/><br \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' \/><br \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='5' \/><\/p>\n<p>            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/><br \/>\n            <input type='hidden' class='gform_hidden' name='state_5' value='WyJbXSIsIjhjN2Q3OTI0NjM0MDhkNmZiMzk5YjNhMDBmYTBmYzVkIl0=' \/><br \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_5' id='gform_target_page_number_5' value='0' \/><br \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_5' id='gform_source_page_number_5' value='1' \/><br \/>\n            <input type='hidden' name='gform_field_values' value='' \/><\/p><\/div>\n<\/p><\/form>\n<\/p><\/div>\n<p>\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_5' id='gform_ajax_frame_5' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe><br \/>\n\t\t                <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 5, 'https:\/\/www.riversidevethospital.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_5').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_5');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_5').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_5').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_5').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_5').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_5').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_5').val();gformInitSpinner( 5, 'https:\/\/www.riversidevethospital.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [5, current_page]);window['gf_submitting_5'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_5').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_5').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [5]);window['gf_submitting_5'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_5').text());}else{jQuery('#gform_5').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"5\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);                if (event && event.defaultPrevented) {                return;         }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_5\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_5\";            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args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script><br \/>\n[\/vc_tta_section][vc_tta_section title=&#8221;Change of Address&#8221; tab_id=&#8221;1601413631093-bbc521b6-f8fc&#8221;]<\/p>\n<div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_6' >\n<div id='gf_6' class='gform_anchor' tabindex='-1'><\/div>\n<div class='gform_heading'>\n<h3 class=\"gform_title\">Change of address<\/h3>\n<p class='gform_description'>\n<\/p><\/div>\n<form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_6' id='gform_6'  action='\/wp-json\/wp\/v2\/pages\/3060\/#gf_6' data-formid='6' novalidate>\n<div class='gf_invisible ginput_recaptchav3' data-sitekey='6LdZfxInAAAAAGDhjfmQg7QmhadVqjI6NyDa8c0_' data-tabindex='0'><input id=\"input_e5e3b1f4b28fc34530a842900157c22e\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_e5e3b1f4b28fc34530a842900157c22e\" value=\"\"\/><\/div>\n<div class='gform-body gform_body'>\n<ul id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below validation_below'>\n<li id=\"field_6_1\" 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_6_1\" >\n<h3>Old Address<\/h3>\n<\/li>\n<li id=\"field_6_2\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_2\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>\n<div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_6_2' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_2_1_container' ><br \/>\n                                        <input type='text' name='input_2.1' id='input_6_2_1' value=''    aria-required='false'    \/><br \/>\n                                        <label for='input_6_2_1' id='input_6_2_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label><br \/>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_6_2_2_container' ><br \/>\n                                        <input type='text' name='input_2.2' id='input_6_2_2' value=''     aria-required='false'   \/><br \/>\n                                        <label for='input_6_2_2' id='input_6_2_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label><br \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_2_3_container' ><br \/>\n                                    <input type='text' name='input_2.3' id='input_6_2_3' value=''    aria-required='false'    \/><br \/>\n                                    <label for='input_6_2_3' id='input_6_2_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label><br \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_2_4_container' ><br \/>\n                                        <input type='text' name='input_2.4' id='input_6_2_4' value=''      aria-required='false'    \/><br \/>\n                                        <label for='input_6_2_4' id='input_6_2_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label><br \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_2_5_container' ><br \/>\n                                    <input type='text' name='input_2.5' id='input_6_2_5' value=''    aria-required='false'    \/><br \/>\n                                    <label for='input_6_2_5' id='input_6_2_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label><br \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_6_2_6_container' ><br \/>\n                                        <select name='input_2.6' id='input_6_2_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select><br \/>\n                                        <label for='input_6_2_6' id='input_6_2_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label><br \/>\n                                    <\/span><\/p>\n<div class='gf_clear gf_clear_complex'><\/div>\n<\/p><\/div>\n<\/li>\n<li id=\"field_6_3\" 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_6_3\" >\n<h3>New Address<\/h3>\n<\/li>\n<li id=\"field_6_4\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_4\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>\n<div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_6_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_4_1_container' ><br \/>\n                                        <input type='text' name='input_4.1' id='input_6_4_1' value=''    aria-required='false'    \/><br \/>\n                                        <label for='input_6_4_1' id='input_6_4_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label><br \/>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_6_4_2_container' ><br \/>\n                                        <input type='text' name='input_4.2' id='input_6_4_2' value=''     aria-required='false'   \/><br \/>\n                                        <label for='input_6_4_2' id='input_6_4_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label><br \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_4_3_container' ><br \/>\n                                    <input type='text' name='input_4.3' id='input_6_4_3' value=''    aria-required='false'    \/><br \/>\n                                    <label for='input_6_4_3' id='input_6_4_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label><br \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_4_4_container' ><br \/>\n                                        <input type='text' name='input_4.4' id='input_6_4_4' value=''      aria-required='false'    \/><br \/>\n                                        <label for='input_6_4_4' id='input_6_4_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label><br \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_4_5_container' ><br \/>\n                                    <input type='text' name='input_4.5' id='input_6_4_5' value=''    aria-required='false'    \/><br \/>\n                                    <label for='input_6_4_5' id='input_6_4_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label><br \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_6_4_6_container' ><br \/>\n                                        <select name='input_4.6' id='input_6_4_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' 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