{"id":3588,"date":"2022-06-28T15:51:34","date_gmt":"2022-06-28T15:51:34","guid":{"rendered":"https:\/\/www.ccvets.com\/?page_id=3588"},"modified":"2022-06-28T15:51:34","modified_gmt":"2022-06-28T15:51:34","slug":"canine-questionnaire","status":"publish","type":"page","link":"https:\/\/www.ccvets.com\/canine-questionnaire\/","title":{"rendered":"Canine Questionnaire"},"content":{"rendered":"<div class=\"wpb-content-wrapper\">\n<p>[vc_row][vc_column]<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 gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_5' >\n<form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/wp-json\/wp\/v2\/pages\/3588\/' data-formid='5' novalidate>\n<div class='gf_invisible ginput_recaptchav3' data-sitekey='6LdZfxInAAAAAGDhjfmQg7QmhadVqjI6NyDa8c0_' data-tabindex='0'><input id=\"input_416e9c570e469f006eac774e58592200\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_416e9c570e469f006eac774e58592200\" value=\"\"\/><\/div>\n<div class='gform-body gform_body'>\n<div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'>\n<div 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<h2>Canine Patient Assessment Questionnaire<\/h2>\n<p><\/p>\n<p>In order to provide top quality care and service for you and your pet Country Chase Veterinary is asking you to answer the following questions to the best of your ability. This questionnaire will help our doctors make recommendations for your pet based on the risk factors that they face individually. This fits our belief that each patient should be treated as an individual rather than taking a one size fits all approach. We want to vaccinate your pet with only the vaccines they need without over-vaccinating them with vaccines they will not need.  We appreciate your help in this process.<\/p>\n<\/div>\n<div id=\"field_5_32\" class=\"gfield gfield--type-text gfield--width-half gf_left_half gfield--width-half gfield_contains_required 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'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_32' id='input_5_32' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<div id=\"field_5_31\" class=\"gfield gfield--type-text gfield--width-half gf_right_half gfield--width-half gfield_contains_required 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'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_31' id='input_5_31' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<div id=\"field_5_29\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required 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'>Patient (Pet) Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_29' id='input_5_29' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<fieldset id=\"field_5_3\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-eleven-twelfths gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_3\" >\n<legend class='gfield_label gform-field-label' >Is your dog exposed to rodents, raccoons or other animals either face to face or shared spaces? For example, do you have wildlife in the space your pet plays or uses the bathroom?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_3'>\n<div class='gchoice gchoice_5_3_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Yes'  id='choice_5_3_0' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_3_0' id='label_5_3_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_3_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='No'  id='choice_5_3_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_3_1' id='label_5_3_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"field_5_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_6\" >\n<legend class='gfield_label gform-field-label' >Is your dog likely to swim in or drink from freshwater ponds, lakes, rivers, or puddles?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_6'>\n<div class='gchoice gchoice_5_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Yes'  id='choice_5_6_0' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_6_0' id='label_5_6_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='No'  id='choice_5_6_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_6_1' id='label_5_6_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"field_5_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_7\" >\n<legend class='gfield_label gform-field-label' >Is your dog having any coughing, sneezing, vomiting or diarrhea?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_7'>\n<div class='gchoice gchoice_5_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Yes'  id='choice_5_7_0' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_7_0' id='label_5_7_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='No'  id='choice_5_7_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_7_1' id='label_5_7_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"field_5_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_9\" >\n<legend class='gfield_label gform-field-label' >Does your dog travel outside of the state?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_9'>\n<div class='gchoice gchoice_5_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Yes'  id='choice_5_9_0' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_9_0' id='label_5_9_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='No'  id='choice_5_9_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_9_1' id='label_5_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"field_5_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_8\" >\n<legend class='gfield_label gform-field-label' >Does your dog go to dog parks, doggie day care or stores?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_8'>\n<div class='gchoice gchoice_5_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Yes'  id='choice_5_8_0' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_8_0' id='label_5_8_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='No'  id='choice_5_8_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_8_1' id='label_5_8_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"field_5_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_36\" >\n<legend class='gfield_label gform-field-label' >Does your dog go to a professional Groomer?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_36'>\n<div class='gchoice gchoice_5_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Yes'  id='choice_5_36_0' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_36_0' id='label_5_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='No'  id='choice_5_36_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_36_1' id='label_5_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_5_33\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_33\" >\n<h3>What do you give your dog for heartworm and flea prevention?<\/h3>\n<\/div>\n<div id=\"field_5_12\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required 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'>Heartworm Prevention:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_12' id='input_5_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<div id=\"field_5_34\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_34\" ><label class='gfield_label gform-field-label' for='input_5_34'>Flea\/Tick Prevention:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_34' id='input_5_34' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<fieldset id=\"field_5_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_13\" >\n<legend class='gfield_label gform-field-label' >Have you missed any doses?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_13'>\n<div class='gchoice gchoice_5_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes'  id='choice_5_13_0' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_13_0' id='label_5_13_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='No'  id='choice_5_13_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_13_1' id='label_5_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"field_5_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_14\" >\n<legend class='gfield_label gform-field-label' >Have you noticed any new or growing lumps on your pet?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_radio'>\n<div class='gfield_radio' id='input_5_14'>\n<div class='gchoice gchoice_5_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Yes'  id='choice_5_14_0' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_14_0' id='label_5_14_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n<div class='gchoice gchoice_5_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='No'  id='choice_5_14_1' onchange='gformToggleRadioOther( this )'    \/><br \/>\n\t\t\t\t\t<label for='choice_5_14_1' id='label_5_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_5_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_5_15\" ><label class='gfield_label gform-field-label' for='input_5_15'>What do you use for home dental care?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_15' id='input_5_15' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<div id=\"field_5_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_5_19\" >\n<h3>What types and brands of foods and treats do you feed your dog?<\/h3>\n<\/div>\n<div id=\"field_5_20\" class=\"gfield gfield--type-text gfield--width-seven-twelfths gfield_contains_required 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'>Dry kibble<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_20' id='input_5_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<div id=\"field_5_21\" class=\"gfield gfield--type-number gfield--width-quarter gfield_contains_required 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'>Amount per day<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_number'><input name='input_21' id='input_5_21' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div>\n<\/div>\n<div id=\"field_5_22\" class=\"gfield gfield--type-text gfield--width-seven-twelfths gfield_contains_required 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'>Wet<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_22' id='input_5_22' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<div id=\"field_5_23\" class=\"gfield gfield--type-number gfield--width-quarter gfield_contains_required 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'>Amount per day<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_number'><input name='input_23' id='input_5_23' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div>\n<\/div>\n<div id=\"field_5_25\" class=\"gfield gfield--type-text 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class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_number'><input name='input_24' id='input_5_24' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div>\n<\/div>\n<div id=\"field_5_26\" 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_26\" ><label class='gfield_label gform-field-label' for='input_5_26'>What other medications and supplements is your dog taking?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_26' id='input_5_26' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<fieldset 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