{"id":175,"date":"2019-09-26T20:45:41","date_gmt":"2019-09-26T20:45:41","guid":{"rendered":"http:\/\/libertyvillageanimalhospital.com\/blog\/?page_id=175"},"modified":"2024-06-19T19:30:57","modified_gmt":"2024-06-19T19:30:57","slug":"client-questionnaire","status":"publish","type":"page","link":"http:\/\/libertyvillageanimalhospital.com\/blog\/client-questionnaire\/","title":{"rendered":"Client Questionnaire"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-1752\"><form id=\"wpforms-form-1752\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"1752\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/blog\/wp-json\/wp\/v2\/pages\/175\" data-token=\"a510288c5cfea7e6b4ef000e60aef869\" data-token-time=\"1775307586\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-1752-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\">Primary Owner  <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1752-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" required><label for=\"wpforms-1752-field_0\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1752-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" required><label for=\"wpforms-1752-field_0-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-1752-field_49-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_49\">Primary Phone number<\/label><input type=\"number\" id=\"wpforms-1752-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" step=\"any\" ><div class=\"wpforms-field-description\">Primary Phone number<\/div><\/div><div id=\"wpforms-1752-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_1\">Primary Owner Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1752-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-1752-field_3-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"3\"><label class=\"wpforms-field-label\">Secondary Owner<\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1752-field_3\" class=\"wpforms-field-name-first\" name=\"wpforms[fields][3][first]\" ><label for=\"wpforms-1752-field_3\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1752-field_3-last\" class=\"wpforms-field-name-last\" name=\"wpforms[fields][3][last]\" ><label for=\"wpforms-1752-field_3-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-1752-field_40-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"40\"><label class=\"wpforms-field-label\">Relationship to Owner<\/label><ul id=\"wpforms-1752-field_40\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1752-field_40_1\" name=\"wpforms[fields][40]\" value=\"Spouse\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_40_1\">Spouse<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1752-field_40_2\" name=\"wpforms[fields][40]\" value=\"Friend\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_40_2\">Friend<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-1752-field_40_3\" name=\"wpforms[fields][40]\" value=\"Family Member\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_40_3\">Family Member<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-1752-field_40_4\" name=\"wpforms[fields][40]\" value=\"Co-worker\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_40_4\">Co-worker<\/label><\/li><\/ul><\/div><div id=\"wpforms-1752-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_6\">Secondary Owner Email <\/label><input type=\"text\" id=\"wpforms-1752-field_6\" class=\"wpforms-field-medium\" name=\"wpforms[fields][6]\" ><\/div><div id=\"wpforms-1752-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_7\">Secondary Owner Phone <\/label><input type=\"text\" id=\"wpforms-1752-field_7\" class=\"wpforms-field-medium\" name=\"wpforms[fields][7]\" ><\/div><div id=\"wpforms-1752-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_8\">Owner Address:<\/label><input type=\"text\" id=\"wpforms-1752-field_8\" class=\"wpforms-field-medium\" name=\"wpforms[fields][8]\" ><\/div><div id=\"wpforms-1752-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_9\">City<\/label><input type=\"text\" id=\"wpforms-1752-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" ><\/div><div id=\"wpforms-1752-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_10\">Province<\/label><input type=\"text\" id=\"wpforms-1752-field_10\" class=\"wpforms-field-medium\" name=\"wpforms[fields][10]\" ><\/div><div id=\"wpforms-1752-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_11\">Postal Code <\/label><input type=\"text\" id=\"wpforms-1752-field_11\" class=\"wpforms-field-medium\" name=\"wpforms[fields][11]\" ><\/div><div id=\"wpforms-1752-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_12\">Medical History - Is there a previous animal hospital we can contact for your pet\u2019s previous medical history?<\/label><input type=\"text\" id=\"wpforms-1752-field_12\" class=\"wpforms-field-medium\" name=\"wpforms[fields][12]\" ><\/div><div id=\"wpforms-1752-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_13\">Hospital Name<\/label><input type=\"text\" id=\"wpforms-1752-field_13\" class=\"wpforms-field-medium\" name=\"wpforms[fields][13]\" ><\/div><div id=\"wpforms-1752-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_14\">Hospital Email<\/label><input type=\"text\" id=\"wpforms-1752-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\" ><\/div><div id=\"wpforms-1752-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_15\">Hospital Phone<\/label><input type=\"text\" id=\"wpforms-1752-field_15\" class=\"wpforms-field-medium\" name=\"wpforms[fields][15]\" ><\/div><div id=\"wpforms-1752-field_16-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"16\"><label class=\"wpforms-field-label\">Pets Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1752-field_16\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][16][first]\" required><label for=\"wpforms-1752-field_16\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1752-field_16-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][16][last]\" required><label for=\"wpforms-1752-field_16-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-1752-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_17\">Breed <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1752-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" required><\/div><div id=\"wpforms-1752-field_18-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_18\">Color<\/label><input type=\"text\" id=\"wpforms-1752-field_18\" class=\"wpforms-field-medium\" name=\"wpforms[fields][18]\" ><\/div><div id=\"wpforms-1752-field_19-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_19\">Pet Date of birth:<\/label><input type=\"text\" id=\"wpforms-1752-field_19\" class=\"wpforms-field-medium\" name=\"wpforms[fields][19]\" ><\/div><div id=\"wpforms-1752-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_20\">Sex<\/label><input type=\"text\" id=\"wpforms-1752-field_20\" class=\"wpforms-field-medium\" name=\"wpforms[fields][20]\" ><\/div><div id=\"wpforms-1752-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_23\">Microchip Number<\/label><input type=\"text\" id=\"wpforms-1752-field_23\" class=\"wpforms-field-medium\" name=\"wpforms[fields][23]\" ><\/div><div id=\"wpforms-1752-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_21\">Spayed\/Neutered?<\/label><input type=\"text\" id=\"wpforms-1752-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" ><\/div><div id=\"wpforms-1752-field_22-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_22\">Does your pet have health insurance?<\/label><input type=\"text\" id=\"wpforms-1752-field_22\" class=\"wpforms-field-medium\" name=\"wpforms[fields][22]\" ><\/div><div id=\"wpforms-1752-field_24-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_24\">Name of insurance company<\/label><input type=\"text\" id=\"wpforms-1752-field_24\" class=\"wpforms-field-medium\" name=\"wpforms[fields][24]\" ><\/div><div id=\"wpforms-1752-field_25-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_25\">Policy Number<\/label><input type=\"text\" id=\"wpforms-1752-field_25\" class=\"wpforms-field-medium\" name=\"wpforms[fields][25]\" ><\/div><div id=\"wpforms-1752-field_26-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_26\">Can we take your pets photo?<\/label><input type=\"text\" id=\"wpforms-1752-field_26\" class=\"wpforms-field-medium\" name=\"wpforms[fields][26]\" ><\/div><div id=\"wpforms-1752-field_27-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_27\">This would be added to their account and potentially social media.<\/label><textarea id=\"wpforms-1752-field_27\" class=\"wpforms-field-medium\" name=\"wpforms[fields][27]\" ><\/textarea><\/div><div id=\"wpforms-1752-field_28-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_28\">Your Pet&#039;s social media account<\/label><textarea id=\"wpforms-1752-field_28\" class=\"wpforms-field-medium\" name=\"wpforms[fields][28]\" ><\/textarea><\/div><div id=\"wpforms-1752-field_29-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_29\">Current Medications\/Supplements<\/label><input type=\"text\" id=\"wpforms-1752-field_29\" class=\"wpforms-field-medium\" name=\"wpforms[fields][29]\" ><div class=\"wpforms-field-description\">Please list all medications, supplements, and preventatives your pet is currently taking. Or N\/A if they are not on any.<\/div><\/div><div id=\"wpforms-1752-field_31-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"31\"><label class=\"wpforms-field-label\">Would you like to discuss any medications, supplements and\/or preventatives with the veterinarian?<\/label><ul id=\"wpforms-1752-field_31\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1752-field_31_1\" name=\"wpforms[fields][31]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_31_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1752-field_31_2\" name=\"wpforms[fields][31]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_31_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-1752-field_52-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"52\"><label class=\"wpforms-field-label\">Have you noticed any of the following?<\/label><ul id=\"wpforms-1752-field_52\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_52_1\" name=\"wpforms[fields][52][]\" value=\"Coughing\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_52_1\">Coughing<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_52_2\" name=\"wpforms[fields][52][]\" value=\"Vomiting\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_52_2\">Vomiting<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_52_5\" name=\"wpforms[fields][52][]\" value=\"Diarrhea\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_52_5\">Diarrhea<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_52_3\" name=\"wpforms[fields][52][]\" value=\"Lameness\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_52_3\">Lameness<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_52_4\" name=\"wpforms[fields][52][]\" value=\"Sneezing\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_52_4\">Sneezing<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_52_6\" name=\"wpforms[fields][52][]\" value=\"Pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_52_6\">Pain<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_52_7\" name=\"wpforms[fields][52][]\" value=\"Behavioural Changes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_52_7\">Behavioural Changes<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_52_8\" name=\"wpforms[fields][52][]\" value=\"New Lumps\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_52_8\">New Lumps<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_52_9\" name=\"wpforms[fields][52][]\" value=\"Difficulty standing\/jumping\/playing\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_52_9\">Difficulty standing\/jumping\/playing<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_52_10\" name=\"wpforms[fields][52][]\" value=\"Presence of fleas, ticks, or tapeworms\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_52_10\">Presence of fleas, ticks, or tapeworms<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_52_11\" name=\"wpforms[fields][52][]\" value=\"Changes in appetite\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_52_11\">Changes in appetite<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_52_12\" name=\"wpforms[fields][52][]\" value=\"Decreased grooming\/change in grooming patterns\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_52_12\">Decreased grooming\/change in grooming patterns<\/label><\/li><\/ul><\/div><div id=\"wpforms-1752-field_33-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"33\"><label class=\"wpforms-field-label\">Has your pet traveled recently or does he\/she travel with you routinely<\/label><ul id=\"wpforms-1752-field_33\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1752-field_33_1\" name=\"wpforms[fields][33]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_33_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1752-field_33_2\" name=\"wpforms[fields][33]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_33_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-1752-field_34-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_34\">Diet<\/label><input type=\"text\" id=\"wpforms-1752-field_34\" class=\"wpforms-field-medium\" name=\"wpforms[fields][34]\" ><div class=\"wpforms-field-description\">Please list the specific name(s) of the food that you are feeding (include both dry and wet food). How much do you feed your pet, and how many times a day?<\/div><\/div><div id=\"wpforms-1752-field_35-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_35\">Are these specifically measured amounts?<\/label><input type=\"text\" id=\"wpforms-1752-field_35\" class=\"wpforms-field-medium\" name=\"wpforms[fields][35]\" ><\/div><div id=\"wpforms-1752-field_36-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_36\">Does your pet receive treats\/human food?<\/label><input type=\"text\" id=\"wpforms-1752-field_36\" class=\"wpforms-field-medium\" name=\"wpforms[fields][36]\" ><\/div><div id=\"wpforms-1752-field_37-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_37\">Would you like to discuss your pet\u2019s nutrition with the veterinarian?<\/label><input type=\"text\" id=\"wpforms-1752-field_37\" class=\"wpforms-field-medium\" name=\"wpforms[fields][37]\" ><\/div><div id=\"wpforms-1752-field_48-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_48\">Other Questions<\/label><input type=\"text\" id=\"wpforms-1752-field_48\" class=\"wpforms-field-medium\" name=\"wpforms[fields][48]\" ><\/div><div id=\"wpforms-1752-field_50-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"50\"><label class=\"wpforms-field-label\">Would you like more information on any of the following? (please check all that apply)<\/label><ul id=\"wpforms-1752-field_50\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_50_1\" name=\"wpforms[fields][50][]\" value=\"Pet health insurance\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_50_1\">Pet health insurance<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_50_2\" name=\"wpforms[fields][50][]\" value=\"Lyme disease\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_50_2\">Lyme disease<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_50_3\" name=\"wpforms[fields][50][]\" value=\"Flea and tick prevention\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_50_3\">Flea and tick prevention<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_50_4\" name=\"wpforms[fields][50][]\" value=\"Heartworm disease\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_50_4\">Heartworm disease<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_50_5\" name=\"wpforms[fields][50][]\" value=\"Internal parasites\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_50_5\">Internal parasites<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_50_6\" name=\"wpforms[fields][50][]\" value=\"Vaccines\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_50_6\">Vaccines<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1752-field_50_7\" name=\"wpforms[fields][50][]\" value=\"Training Behavior\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_50_7\">Training Behavior<\/label><\/li><\/ul><\/div><div id=\"wpforms-1752-field_45-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_45\">Rate your pet\u2019s water consumption<\/label><input type=\"text\" id=\"wpforms-1752-field_45\" class=\"wpforms-field-medium\" name=\"wpforms[fields][45]\" ><\/div><div id=\"wpforms-1752-field_47-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"47\"><label class=\"wpforms-field-label\">Has this changed recently?<\/label><ul id=\"wpforms-1752-field_47\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1752-field_47_1\" name=\"wpforms[fields][47]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_47_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1752-field_47_2\" name=\"wpforms[fields][47]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_47_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-1752-field_41-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"41\"><label class=\"wpforms-field-label\">How did you hear about us?<\/label><ul id=\"wpforms-1752-field_41\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1752-field_41_1\" name=\"wpforms[fields][41]\" value=\"Walked\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_41_1\">Walked<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1752-field_41_2\" name=\"wpforms[fields][41]\" value=\"Drive by\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_41_2\">Drive by<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-1752-field_41_3\" name=\"wpforms[fields][41]\" value=\"Signage\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_41_3\">Signage<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-1752-field_41_4\" name=\"wpforms[fields][41]\" value=\"Internet search\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_41_4\">Internet search<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-1752-field_41_5\" name=\"wpforms[fields][41]\" value=\"Social media\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_41_5\">Social media<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-1752-field_41_6\" name=\"wpforms[fields][41]\" value=\"Word of mouth\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_41_6\">Word of mouth<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-1752-field_41_7\" name=\"wpforms[fields][41]\" value=\"Friend or Family\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1752-field_41_7\">Friend or Family<\/label><\/li><\/ul><\/div><div id=\"wpforms-1752-field_42-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-1752-field_42\">Name of referral:<\/label><input type=\"text\" id=\"wpforms-1752-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\" ><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"1752\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"http:\/\/libertyvillageanimalhospital.com\/blog\/wp-json\/wp\/v2\/pages\/175\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-1752\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"http:\/\/libertyvillageanimalhospital.com\/blog\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\n<p class=\"text-white\"><strong>To schedule an appointment, please call into the clinic to discuss availability.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>To schedule an appointment, please call into the clinic to discuss availability.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"_links":{"self":[{"href":"http:\/\/libertyvillageanimalhospital.com\/blog\/wp-json\/wp\/v2\/pages\/175"}],"collection":[{"href":"http:\/\/libertyvillageanimalhospital.com\/blog\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"http:\/\/libertyvillageanimalhospital.com\/blog\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"http:\/\/libertyvillageanimalhospital.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/libertyvillageanimalhospital.com\/blog\/wp-json\/wp\/v2\/comments?post=175"}],"version-history":[{"count":2,"href":"http:\/\/libertyvillageanimalhospital.com\/blog\/wp-json\/wp\/v2\/pages\/175\/revisions"}],"predecessor-version":[{"id":1755,"href":"http:\/\/libertyvillageanimalhospital.com\/blog\/wp-json\/wp\/v2\/pages\/175\/revisions\/1755"}],"wp:attachment":[{"href":"http:\/\/libertyvillageanimalhospital.com\/blog\/wp-json\/wp\/v2\/media?parent=175"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}