{"id":1208,"date":"2025-05-24T04:54:43","date_gmt":"2025-05-24T09:54:43","guid":{"rendered":"https:\/\/simplefixrx.com\/?page_id=1208"},"modified":"2025-07-25T13:07:10","modified_gmt":"2025-07-25T18:07:10","slug":"order","status":"publish","type":"page","link":"https:\/\/simplefixrx.com\/es\/order\/","title":{"rendered":"1 &#8211; GLP-1 Questionnaire Form"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_2' style='display:none'><style>#gform_wrapper_2[data-form-index=\"0\"].gform-theme,[data-parent-form=\"2_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: #585e6a;--gf-color-out-ctrl-dark-rgb: 88, 94, 106;--gf-color-out-ctrl-dark-darker: #112337;--gf-color-out-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-color-in-ctrl: #fff;--gf-color-in-ctrl-rgb: 255, 255, 255;--gf-color-in-ctrl-contrast: #112337;--gf-color-in-ctrl-contrast-rgb: 17, 35, 55;--gf-color-in-ctrl-darker: #F5F5F5;--gf-color-in-ctrl-lighter: #FFFFFF;--gf-color-in-ctrl-primary: #204ce5;--gf-color-in-ctrl-primary-rgb: 32, 76, 229;--gf-color-in-ctrl-primary-contrast: #fff;--gf-color-in-ctrl-primary-contrast-rgb: 255, 255, 255;--gf-color-in-ctrl-primary-darker: #001AB3;--gf-color-in-ctrl-primary-lighter: #527EFF;--gf-color-in-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-in-ctrl-light-rgb: 17, 35, 55;--gf-color-in-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-in-ctrl-light-lighter: #F5F5F5;--gf-color-in-ctrl-dark: #585e6a;--gf-color-in-ctrl-dark-rgb: 88, 94, 106;--gf-color-in-ctrl-dark-darker: #112337;--gf-color-in-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-radius: 3px;--gf-font-size-secondary: 14px;--gf-font-size-tertiary: 13px;--gf-icon-ctrl-number: url(\"data:image\/svg+xml,%3Csvg width='8' height='14' viewBox='0 0 8 14' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-select: url(\"data:image\/svg+xml,%3Csvg width='10' height='6' viewBox='0 0 10 6' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg width='640' height='640' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_2' id='gform_2'  action='\/es\/wp-json\/wp\/v2\/pages\/1208#gf_2' data-formid='2' novalidate><input id=partial_entry_id_2 class=\"partial_entry_id\" type=hidden name=\"partial_entry_id\" value=\"pending\" data-form_id=\"2\"\/>\n        <div id='gf_progressbar_wrapper_2' class='gf_progressbar_wrapper' data-start-at-zero='1'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>11<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_0' style='width:0%;'><span>0%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_2_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_187\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_187'>Doctor&#039;s Notes<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_187' id='input_2_187' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_122\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full nt-step-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Let's Get Started<\/h2><\/div><div id=\"field_2_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full first_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_1'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_2_1' type='text' value='' class='large'    placeholder='First Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_2\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full last_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_2'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_2_2' type='text' value='' class='large'    placeholder='Last Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_3\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_3'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_2_3' type='email' value='' class='large'   placeholder='Email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_4'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_2_4' type='tel' value='' class='large'  placeholder='Phone' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_5\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-full date_of_birth gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date Of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_2_5' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_2_5_1_container'>\n                                            <input type='number' maxlength='2' name='input_5[]' id='input_2_5_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_2_5_1' class='gform-field-label gform-field-label--type-sub '>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_2_5_2_container'>\n                                            <input type='number' maxlength='2' name='input_5[]' id='input_2_5_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_2_5_2' class='gform-field-label gform-field-label--type-sub '>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_2_5_3_container'>\n                                            <input type='number' maxlength='4' name='input_5[]' id='input_2_5_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_2_5_3' class='gform-field-label gform-field-label--type-sub '>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_2_112\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_112'>Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_112' id='input_2_112' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please Select...<\/option><option value='Female' >Female<\/option><option value='Male' >Male<\/option><\/select><\/div><\/div><div id=\"field_2_7\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_7'>State<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_2_7' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please Select...<\/option><option value='Texas' >Texas<\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/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='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='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><\/select><\/div><\/div><div id=\"field_2_228\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_228'>Google Ad Source<\/label><div class='ginput_container ginput_container_text'><input name='input_228' id='input_2_228' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_192\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><h3>SimpleFixRx is Currently Not Available in Your State<\/h3>\n<p>We're sorry, but SimpleFixRx is currently not available in your selected state. Please reach out to <a href=\"mailto:support@simplefixrx.com\">support@simplefixrx.com<\/a>. We may still be able to help you get the prescription you are looking for!<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_2_169' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_2' class='gform_page' data-js='page-field-id-169' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_125\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full nt-step-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Medical History<\/h2><\/div><fieldset id=\"field_2_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >What are your weight loss goals?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_24'>\n\t\t\t<div class='gchoice gchoice_2_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Lose 1-20lbs for good'  id='choice_2_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_24_0' id='label_2_24_0' class='gform-field-label gform-field-label--type-inline'>Lose 1-20lbs for good<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Lose 21-50lbs for good'  id='choice_2_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_24_1' id='label_2_24_1' class='gform-field-label gform-field-label--type-inline'>Lose 21-50lbs for good<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_24_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Lose over 50 for good'  id='choice_2_24_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_24_2' id='label_2_24_2' class='gform-field-label gform-field-label--type-inline'>Lose over 50 for good<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_24_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Maintain my healthy weight'  id='choice_2_24_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_24_3' id='label_2_24_3' class='gform-field-label gform-field-label--type-inline'>Maintain my healthy weight<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_24_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='None of the above'  id='choice_2_24_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_24_4' id='label_2_24_4' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_24_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value=''  id='choice_2_24_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_24_5' id='label_2_24_5' class='gform-field-label gform-field-label--type-inline'>other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_266\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >What weight loss initiatives have you tried in the past? Select all that apply<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_266'>\n\t\t\t<div class='gchoice gchoice_2_266_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_266' type='radio' value='Lose 1-20lbs for good'  id='choice_2_266_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_266_0' id='label_2_266_0' class='gform-field-label gform-field-label--type-inline'>Exercise<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_266_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_266' type='radio' value='Lose 21-50lbs for good'  id='choice_2_266_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_266_1' id='label_2_266_1' class='gform-field-label gform-field-label--type-inline'>Dieting<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_266_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_266' type='radio' value='Lose over 50 for good'  id='choice_2_266_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_266_2' id='label_2_266_2' class='gform-field-label gform-field-label--type-inline'>Weight-loss Supplements<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_266_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_266' type='radio' value='Maintain my healthy weight'  id='choice_2_266_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_266_3' id='label_2_266_3' class='gform-field-label gform-field-label--type-inline'>Intermittent Fasting<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_266_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_266' type='radio' value='None of the above'  id='choice_2_266_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_266_4' id='label_2_266_4' class='gform-field-label gform-field-label--type-inline'>None of the Above<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_265\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you seen a doctor in the past 12 months?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_265'>\n\t\t\t<div class='gchoice gchoice_2_265_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_265' type='radio' value='No, I have not seen a doctor in the past 12 months.'  id='choice_2_265_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_265_0' id='label_2_265_0' class='gform-field-label gform-field-label--type-inline'>No, I have not seen a doctor in the past 12 months.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_265_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_265' type='radio' value='Yes, I have seen a doctor in the past 12 months.'  id='choice_2_265_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_265_1' id='label_2_265_1' class='gform-field-label gform-field-label--type-inline'>Yes, I have seen a doctor in the past 12 months.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_25\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_25'>Your Weight (Lbs)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_25' id='input_2_25' type='number' step='any'   value='' class='large'    placeholder='Lbs' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_26\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_26'>Height (Feet)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_26' id='input_2_26' type='number' step='any'   value='' class='large'    placeholder='Feet' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_27\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_27'>Height (Inches)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_27' id='input_2_27' type='number' step='any'   value='' class='large'    placeholder='Inches' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_29\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_29'>Bmi<\/label><div class='ginput_container ginput_container_number'><input name='input_29' id='input_2_29' type='text' step='any'   value='' class='large gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_71\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter weight gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_71'>Weight(Lbs)<\/label><div class='ginput_container ginput_container_number'><input name='input_71' id='input_2_71' type='text' step='any'   value='' class='large gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_72\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_72'>Height (feet\/inches)<\/label><div class='ginput_container ginput_container_number'><input name='input_72' id='input_2_72' type='text' step='any'   value='' class='large gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_73\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_73'>Height (cm)<\/label><div class='ginput_container ginput_container_number'><input name='input_73' id='input_2_73' type='text' step='any'   value='' class='large gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_2_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full medical_condition gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you been diagnosed with any of these conditions?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_30'>\n\t\t\t<div class='gchoice gchoice_2_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='High Blood Pressure'  id='choice_2_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_30_0' id='label_2_30_0' class='gform-field-label gform-field-label--type-inline'>High Blood Pressure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Type 2 Diabetes'  id='choice_2_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_30_1' id='label_2_30_1' class='gform-field-label gform-field-label--type-inline'>Type 2 Diabetes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_30_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='High Cholesterol'  id='choice_2_30_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_30_2' id='label_2_30_2' class='gform-field-label gform-field-label--type-inline'>High Cholesterol<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_30_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Pulmonary Condition'  id='choice_2_30_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_30_3' id='label_2_30_3' class='gform-field-label gform-field-label--type-inline'>Pulmonary Condition<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_30_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='None'  id='choice_2_30_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_30_4' id='label_2_30_4' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_30_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Other'  id='choice_2_30_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_30_5' id='label_2_30_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >How often do you exercise?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_31'>\n\t\t\t<div class='gchoice gchoice_2_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='3-4 days a week'  id='choice_2_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_31_0' id='label_2_31_0' class='gform-field-label gform-field-label--type-inline'>3-4 days a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='2-3 days a week'  id='choice_2_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_31_1' id='label_2_31_1' class='gform-field-label gform-field-label--type-inline'>2-3 days a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_31_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Very little'  id='choice_2_31_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_31_2' id='label_2_31_2' class='gform-field-label gform-field-label--type-inline'>Very little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_31_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Never'  id='choice_2_31_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_31_3' id='label_2_31_3' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_31_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Other'  id='choice_2_31_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_31_4' id='label_2_31_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_32'>What type of exercise do you do?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_2_32' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_178\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Which of the following weight loss medications have you tried?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_178'><div class='gchoice gchoice_2_178_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_178.1' type='checkbox'  value='GLP-1'  id='choice_2_178_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_178_1' id='label_2_178_1' class='gform-field-label gform-field-label--type-inline'>GLP-1<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_178_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_178.2' type='checkbox'  value='GLP-1\/GIP'  id='choice_2_178_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_178_2' id='label_2_178_2' class='gform-field-label gform-field-label--type-inline'>GLP-1\/GIP<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_178_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_178.3' type='checkbox'  value='Orlistat (Xenical, Alli)'  id='choice_2_178_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_178_3' id='label_2_178_3' class='gform-field-label gform-field-label--type-inline'>Orlistat (Xenical, Alli)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_178_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_178.4' type='checkbox'  value='Phentermine-topiramate (Qsymia)'  id='choice_2_178_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_178_4' id='label_2_178_4' class='gform-field-label gform-field-label--type-inline'>Phentermine-topiramate (Qsymia)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_178_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_178.5' type='checkbox'  value='Reg Phentermine 37.5 mg'  id='choice_2_178_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_178_5' id='label_2_178_5' class='gform-field-label gform-field-label--type-inline'>Reg Phentermine 37.5 mg<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_178_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_178.6' type='checkbox'  value='Naltrexone-bupropion (Contrave)'  id='choice_2_178_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_178_6' id='label_2_178_6' class='gform-field-label gform-field-label--type-inline'>Naltrexone-bupropion (Contrave)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_178_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_178.7' type='checkbox'  value='Liraglutide (Saxenda)'  id='choice_2_178_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_178_7' id='label_2_178_7' class='gform-field-label gform-field-label--type-inline'>Liraglutide (Saxenda)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_178_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_178.8' type='checkbox'  value='None, I have not tried Rx weight management meds'  id='choice_2_178_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_178_8' id='label_2_178_8' class='gform-field-label gform-field-label--type-inline'>None, I have not tried Rx weight management meds<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you had serious issues with gallbladder within the past 12 months? *<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_34'>\n\t\t\t<div class='gchoice gchoice_2_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Pain in your upper stomach (abdomen)'  id='choice_2_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_0' id='label_2_34_0' class='gform-field-label gform-field-label--type-inline'>Pain in your upper stomach (abdomen)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Yellowing of the skin or eyes (jaundice)'  id='choice_2_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_1' id='label_2_34_1' class='gform-field-label gform-field-label--type-inline'>Yellowing of the skin or eyes (jaundice)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Clay-colored stools'  id='choice_2_34_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_2' id='label_2_34_2' class='gform-field-label gform-field-label--type-inline'>Clay-colored stools<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='I have active Gallbladder Disease'  id='choice_2_34_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_3' id='label_2_34_3' class='gform-field-label gform-field-label--type-inline'>I have active Gallbladder Disease<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='No, I do not have any of these symptoms'  id='choice_2_34_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_4' id='label_2_34_4' class='gform-field-label gform-field-label--type-inline'>No, I do not have any of these symptoms<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you been diagnosed with inflammation of your pancreas (pancreatitis) in the past 6 months?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_35'>\n\t\t\t<div class='gchoice gchoice_2_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_2_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_35_0' id='label_2_35_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_2_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_35_1' id='label_2_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you been diagnosed with kidney disease in the past 12 months? *<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_36'>\n\t\t\t<div class='gchoice gchoice_2_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Yes'  id='choice_2_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_36_0' id='label_2_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='No'  id='choice_2_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_36_1' id='label_2_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have sleep conditions such as sleep apnea?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_37'>\n\t\t\t<div class='gchoice gchoice_2_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Yes, I have Sleep Apnea'  id='choice_2_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_37_0' id='label_2_37_0' class='gform-field-label gform-field-label--type-inline'>Yes, I have Sleep Apnea<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='No, I do not have Sleep Apnea'  id='choice_2_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_37_1' id='label_2_37_1' class='gform-field-label gform-field-label--type-inline'>No, I do not have Sleep Apnea<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you on hormone therapy?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_38'>\n\t\t\t<div class='gchoice gchoice_2_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Creams'  id='choice_2_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_38_0' id='label_2_38_0' class='gform-field-label gform-field-label--type-inline'>Creams<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Pellet'  id='choice_2_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_38_1' id='label_2_38_1' class='gform-field-label gform-field-label--type-inline'>Pellet<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_38_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No, I am not on hormone therapy'  id='choice_2_38_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_38_2' id='label_2_38_2' class='gform-field-label gform-field-label--type-inline'>No, I am not on hormone therapy<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_38_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Not currently, but I should be'  id='choice_2_38_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_38_3' id='label_2_38_3' class='gform-field-label gform-field-label--type-inline'>Not currently, but I should be<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_38_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='I am happy with my hormone health'  id='choice_2_38_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_38_4' id='label_2_38_4' class='gform-field-label gform-field-label--type-inline'>I am happy with my hormone health<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_39\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >In the past 12 months, I...<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_39'>\n\t\t\t<div class='gchoice gchoice_2_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Experienced no mental health problems, ie anxiety, depression'  id='choice_2_39_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_39_0' id='label_2_39_0' class='gform-field-label gform-field-label--type-inline'>Experienced no mental health problems, ie anxiety, depression<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='I am on medication, but feel in control of my mental health'  id='choice_2_39_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_39_1' id='label_2_39_1' class='gform-field-label gform-field-label--type-inline'>I am on medication, but feel in control of my mental health<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_39_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='I deal with stress, but no medication. Some days are stressful, but I feel okay.'  id='choice_2_39_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_39_2' id='label_2_39_2' class='gform-field-label gform-field-label--type-inline'>I deal with stress, but no medication. Some days are stressful, but I feel okay.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_40\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever been diagnosed with medullary thyroid cancer or MEN syndrome?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_40'>\n\t\t\t<div class='gchoice gchoice_2_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Yes'  id='choice_2_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_40_0' id='label_2_40_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='No'  id='choice_2_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_40_1' id='label_2_40_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have an active eating disorder?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_41'>\n\t\t\t<div class='gchoice gchoice_2_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Yes'  id='choice_2_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_41_0' id='label_2_41_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='No'  id='choice_2_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_41_1' id='label_2_41_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_182\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you currently pregnant or breastfeeding? GLP-1 cannot be taken while breastfeeding.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_182'>\n\t\t\t<div class='gchoice gchoice_2_182_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_182' type='radio' value='Yes'  id='choice_2_182_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_182_0' id='label_2_182_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_182_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_182' type='radio' value='No'  id='choice_2_182_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_182_1' id='label_2_182_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you planning on getting pregnant in the next year?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_43'>\n\t\t\t<div class='gchoice gchoice_2_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Yes'  id='choice_2_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_43_0' id='label_2_43_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='No'  id='choice_2_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_43_1' id='label_2_43_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have type 1 diabetes<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_44'>\n\t\t\t<div class='gchoice gchoice_2_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_2_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_44_0' id='label_2_44_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_2_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_44_1' id='label_2_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you currently struggling with substance abuse or dependency problems?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_45'>\n\t\t\t<div class='gchoice gchoice_2_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Yes'  id='choice_2_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_45_0' id='label_2_45_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='No'  id='choice_2_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_45_1' id='label_2_45_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_46\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you had bariatric surgery within the past 18 months<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_46'>\n\t\t\t<div class='gchoice gchoice_2_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Yes'  id='choice_2_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_46_0' id='label_2_46_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='No'  id='choice_2_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_46_1' id='label_2_46_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_155\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you visited us before?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_155'>\n\t\t\t<div class='gchoice gchoice_2_155_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='Yes, I\u2019m a returning patient'  id='choice_2_155_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_155_0' id='label_2_155_0' class='gform-field-label gform-field-label--type-inline'>Yes, I\u2019m a returning patient<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_155_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='No, I\u2019m a new patient'  id='choice_2_155_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_155_1' id='label_2_155_1' class='gform-field-label gform-field-label--type-inline'>No, I\u2019m a new patient<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_264\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Which type of consultation would you prefer?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_264'>\n\t\t\t<div class='gchoice gchoice_2_264_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_264' type='radio' value='Video'  id='choice_2_264_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_264_0' id='label_2_264_0' class='gform-field-label gform-field-label--type-inline'>Video<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_264_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_264' type='radio' value='Phone'  id='choice_2_264_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_264_1' id='label_2_264_1' class='gform-field-label gform-field-label--type-inline'>Phone<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_264_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_264' type='radio' value='Asynchronous\/Email and Text Message (Fastest Option)'  id='choice_2_264_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_264_2' id='label_2_264_2' class='gform-field-label gform-field-label--type-inline'>Asynchronous\/Email and Text Message (Fastest Option)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_49\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_49'>Please list current medications. (including any medications you\u2019ve taken in the last 45 days)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_49' id='input_2_49' class='textarea small'    placeholder='Please list current medications. (including any medications you\u2019ve taken in the last 45 days)'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_50\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_50'>Is the any additional medical history our provider should know during the consult?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_50' id='input_2_50' class='textarea small'    placeholder='Is the any additional medical history our provider should know during the consult?'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_8' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_2_8' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_3' class='gform_page' data-js='page-field-id-8' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_159\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>***Important Notice:<\/h2>\n\n<b>New compliance measures<\/b> require all new (or) returning patients seeking an increase in their medication to schedule a call with a physician.\n\nIf you are a new patient, or are seeking an increase in your dose, you will be directed to schedule your online doctor consult immediately following your payment.\n\n<b>If answered incorrectly,<\/b> requested medication could be delayed (or) your order could be canceled and payment refunded.\n\nFor any question, please contact <a href=\"mailto:support@simplefixrx.com\">support@simplefixrx.com<\/a><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_162' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_2_162' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_4' class='gform_page' data-js='page-field-id-162' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_163\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full nt-step-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Weight Management Rx History<\/h2><\/div><div id=\"field_2_168\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_168'>Have you taken any GLP-1 weight loss medications? Please list all medications.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_168' id='input_2_168' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_167\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Did any of the following side effects cause you to discontinue treatment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_167'><div class='gchoice gchoice_2_167_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.1' type='checkbox'  value='Nausea'  id='choice_2_167_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_167_1' id='label_2_167_1' class='gform-field-label gform-field-label--type-inline'>Nausea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_167_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.2' type='checkbox'  value='Diarrhea'  id='choice_2_167_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_167_2' id='label_2_167_2' class='gform-field-label gform-field-label--type-inline'>Diarrhea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_167_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.3' type='checkbox'  value='Stomach (abdominal) pain'  id='choice_2_167_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_167_3' id='label_2_167_3' class='gform-field-label gform-field-label--type-inline'>Stomach (abdominal) pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_167_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.4' type='checkbox'  value='Vomiting'  id='choice_2_167_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_167_4' id='label_2_167_4' class='gform-field-label gform-field-label--type-inline'>Vomiting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_167_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.5' type='checkbox'  value='Constipation'  id='choice_2_167_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_167_5' id='label_2_167_5' class='gform-field-label gform-field-label--type-inline'>Constipation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_167_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.6' type='checkbox'  value='No side effects'  id='choice_2_167_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_167_6' id='label_2_167_6' class='gform-field-label gform-field-label--type-inline'>No side effects<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_167_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.7' type='checkbox'  value='Other...'  id='choice_2_167_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_167_7' id='label_2_167_7' class='gform-field-label gform-field-label--type-inline'>Other...<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_242\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_242'>Please specify other side effects caused by taking any GLP-1 weight loss medications...<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_242' id='input_2_242' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you previously purchase your weight loss medication from SimpleFix?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_11'>\n\t\t\t<div class='gchoice gchoice_2_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='No'  id='choice_2_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_11_0' id='label_2_11_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Yes'  id='choice_2_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_11_1' id='label_2_11_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_165\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_165'>Where did you purchase your weight loss medication from previously?<\/label><div class='ginput_container ginput_container_text'><input name='input_165' id='input_2_165' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >What was the ending medication and strength of your previous treatment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_20'>\n\t\t\t<div class='gchoice gchoice_2_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='0.5 mg GLP-1 (approximate)'  id='choice_2_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_20_0' id='label_2_20_0' class='gform-field-label gform-field-label--type-inline'>0.5 mg GLP-1 (approximate)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='1.0 mg GLP-1 (approximate)'  id='choice_2_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_20_1' id='label_2_20_1' class='gform-field-label gform-field-label--type-inline'>1.0 mg GLP-1 (approximate)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_20_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='1.7 mg GLP-1 (approximate)'  id='choice_2_20_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_20_2' id='label_2_20_2' class='gform-field-label gform-field-label--type-inline'>1.7 mg GLP-1 (approximate)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_20_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='2.4 mg GLP-1 (approximate)'  id='choice_2_20_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_20_3' id='label_2_20_3' class='gform-field-label gform-field-label--type-inline'>2.4 mg GLP-1 (approximate)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_20_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='5 mg GLP-1\/GIP (approximate)'  id='choice_2_20_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_20_4' id='label_2_20_4' class='gform-field-label gform-field-label--type-inline'>5 mg GLP-1\/GIP (approximate)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_20_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='7.5 mg GLP-1\/GIP (approximate)'  id='choice_2_20_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_20_5' id='label_2_20_5' class='gform-field-label gform-field-label--type-inline'>7.5 mg GLP-1\/GIP (approximate)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_20_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='10 mg GLP-1\/GIP (approximate)'  id='choice_2_20_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_20_6' id='label_2_20_6' class='gform-field-label gform-field-label--type-inline'>10 mg GLP-1\/GIP (approximate)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_20_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='12.5 mg GLP-1\/GIP (approximate)'  id='choice_2_20_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_20_7' id='label_2_20_7' class='gform-field-label gform-field-label--type-inline'>12.5 mg GLP-1\/GIP (approximate)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_20_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='15 mg GLP-1\/GIP (approximate)'  id='choice_2_20_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_20_8' id='label_2_20_8' class='gform-field-label gform-field-label--type-inline'>15 mg GLP-1\/GIP (approximate)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_20_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Unknown'  id='choice_2_20_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_20_9' id='label_2_20_9' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >What was your most recent medication\/dosage strength?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_13'>\n\t\t\t<div class='gchoice gchoice_2_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='0.5 mg GLP-1'  id='choice_2_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_13_0' id='label_2_13_0' class='gform-field-label gform-field-label--type-inline'>0.5 mg GLP-1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='1.0 mg GLP-1'  id='choice_2_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_13_1' id='label_2_13_1' class='gform-field-label gform-field-label--type-inline'>1.0 mg GLP-1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='1.7 mg GLP-1'  id='choice_2_13_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_13_2' id='label_2_13_2' class='gform-field-label gform-field-label--type-inline'>1.7 mg GLP-1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_13_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='2.4 mg GLP-1'  id='choice_2_13_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_13_3' id='label_2_13_3' class='gform-field-label gform-field-label--type-inline'>2.4 mg GLP-1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_13_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='5 mg GLP-1\/GIP'  id='choice_2_13_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_13_4' id='label_2_13_4' class='gform-field-label gform-field-label--type-inline'>5 mg GLP-1\/GIP<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_13_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='7.5 mg GLP-1\/GIP'  id='choice_2_13_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_13_5' id='label_2_13_5' class='gform-field-label gform-field-label--type-inline'>7.5 mg GLP-1\/GIP<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_13_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='10 mg GLP-1\/GIP'  id='choice_2_13_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_13_6' id='label_2_13_6' class='gform-field-label gform-field-label--type-inline'>10 mg GLP-1\/GIP<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_13_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='12.5 mg GLP-1\/GIP'  id='choice_2_13_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_13_7' id='label_2_13_7' class='gform-field-label gform-field-label--type-inline'>12.5 mg GLP-1\/GIP<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_13_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='15 mg GLP-1\/GIP'  id='choice_2_13_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_13_8' id='label_2_13_8' class='gform-field-label gform-field-label--type-inline'>15 mg GLP-1\/GIP<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Would you like the strength of your prescription increased?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_22'>\n\t\t\t<div class='gchoice gchoice_2_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Yes, I&#039;m having a slow or plateau in weight loss and would like to increase the strength of my prescription according to protocol.'  id='choice_2_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_22_0' id='label_2_22_0' class='gform-field-label gform-field-label--type-inline'>Yes, I'm having a slow or plateau in weight loss and would like to increase the strength of my prescription according to protocol.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='No, I&#039;m happy with the amount I&#039;m losing and do not wish to increase the strength of my prescription.'  id='choice_2_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_22_1' id='label_2_22_1' class='gform-field-label gform-field-label--type-inline'>No, I'm happy with the amount I'm losing and do not wish to increase the strength of my prescription.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_233\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Studies shows adding B12 can help reduce nausea and increase energy. Is feeling energetic important to you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_233'>\n\t\t\t<div class='gchoice gchoice_2_233_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_233' type='radio' value='Yes'  id='choice_2_233_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_233_0' id='label_2_233_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_233_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_233' type='radio' value='No'  id='choice_2_233_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_233_1' id='label_2_233_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_243\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If Yes, would you like us to add a b12 to your request?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_243'>\n\t\t\t<div class='gchoice gchoice_2_243_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_243' type='radio' value='Yes'  id='choice_2_243_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_243_0' id='label_2_243_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_243_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_243' type='radio' value='No'  id='choice_2_243_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_243_1' id='label_2_243_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_236\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Adding glycine to your weight lost regime it can help muscle retention. Is muscle retention important to you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_236'>\n\t\t\t<div class='gchoice gchoice_2_236_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_236' type='radio' value='Yes'  id='choice_2_236_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_236_0' id='label_2_236_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_236_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_236' type='radio' value='No'  id='choice_2_236_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_236_1' id='label_2_236_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_235\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you had gastrointestinal issues or nausea while on GLP-1 medications?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_235'>\n\t\t\t<div class='gchoice gchoice_2_235_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_235' type='radio' value='Yes'  id='choice_2_235_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_235_0' id='label_2_235_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_235_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_235' type='radio' value='No'  id='choice_2_235_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_235_1' id='label_2_235_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_244\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If Yes, would you like us to add nausea medication to your request?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_244'>\n\t\t\t<div class='gchoice gchoice_2_244_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_244' type='radio' value='Yes'  id='choice_2_244_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_244_0' id='label_2_244_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_244_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_244' type='radio' value='No'  id='choice_2_244_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_244_1' id='label_2_244_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_57' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_2_57' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_5' class='gform_page' data-js='page-field-id-57' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_127\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full nt-step-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>READ OUR TERMS & CONDITIONS POLICY<\/h2><\/div><div id=\"field_2_58\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"padding: 20px; border: 1px solid #BEBEBE; border-radius: 5px;\">\n<div><strong>TELEMEDICINE PATIENT CONSENT PURPOSE:<\/strong><\/div>\n\n<p>The purpose of \"Telemedicine Consent Form\" is to get the patient's consent in order to participate in appointments of telemedicine cares.<\/p>\n<p><strong>RECORDS:<\/strong> Telecommunications with patients will not be recorded and stored. Patients' medical information obtained by the diagnosis and analysis can be used anonymously for further improvements in scientific studies. TELEMEDICINE INFORMATION: The medical information related to history, records and tests of the patient will be discussed during the telemedicine appointment with video and audio.<\/p>\n\n<p><strong>ACCESS:<\/strong> The patient accepts that he\/she needs access to PC, laptop, or mobile device and a good internet connection in order to have an efficient telemedicine appointment. PATIENT RIGHTS: The patient can withdraw his\/her consent at any time and can ask the questions related to telemedicine appointments and technical requirements for telecommunication. By signing this form, I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices. I understand that I can withdraw the consent at any time and that will not affect any of my future treatment procedures. I understand that I can be charged the additional fees that my insurance does not cover. I accept that I authorize health care professionals and use telemedicine for my treatment and diagnosis.<\/p>\n<\/div><\/div><fieldset id=\"field_2_59\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I agree to terms and conditions<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_59'><div class='gchoice gchoice_2_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='I agree to terms and conditions'  id='choice_2_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_59_1' id='label_2_59_1' class='gform-field-label gform-field-label--type-inline'>I agree to terms and conditions<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_60\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >By using SimpleFix you are consenting to the practices described in the privacy policy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_60'><div class='gchoice gchoice_2_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='By using SimpleFix you are consenting to the practices described in the privacy policy'  id='choice_2_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_60_1' id='label_2_60_1' class='gform-field-label gform-field-label--type-inline'>By using SimpleFix you are consenting to the practices described in the privacy policy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_61' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_2_61' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_6' class='gform_page' data-js='page-field-id-61' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_128\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full nt-step-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Sign & Consent<\/h2><\/div><div id=\"field_2_62\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h5>By signing here, you agree that you have read HIPAA, telemedicine consent, Disclosure and agree that you are the individual in DL and Photo. SimplefixRx uses CareValidate for medical decisions and patient care.<\/h5><\/div><div id=\"field_2_64\" class=\"gfield gfield--type-signature gfield--input-type-signature nt-signature-box field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_64'>Sign here<\/label><input type='hidden' value='' name='input_64' id='input_2_64_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_2_64_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_2_64' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/simplefixrx.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_2_64_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_2_64_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_2_64_data' name='input_2_64_data' value=''><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_65' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_2_65' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_7' class='gform_page' data-js='page-field-id-65' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_129\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full nt-step-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Shipping & Billing Information<\/h2><\/div><fieldset id=\"field_2_170\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Shipping Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \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_2_170' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_170_1_container' >\n                                        <input type='text' name='input_170.1' id='input_2_170_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                        <label for='input_2_170_1' id='input_2_170_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_2_170_2_container' >\n                                        <input type='text' name='input_170.2' id='input_2_170_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/>\n                                        <label for='input_2_170_2' id='input_2_170_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_170_3_container' >\n                                    <input type='text' name='input_170.3' id='input_2_170_3' value=''    aria-required='true'   autocomplete=\"address-level2\" \/>\n                                    <label for='input_2_170_3' id='input_2_170_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_170_4_container' >\n                                        <select name='input_170.4' id='input_2_170_4'     aria-required='true'   autocomplete=\"address-level1\" ><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>\n                                        <label for='input_2_170_4' id='input_2_170_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_170_5_container' >\n                                    <input type='text' name='input_170.5' id='input_2_170_5' value=''    aria-required='true'   autocomplete=\"postal-code\" \/>\n                                    <label for='input_2_170_5' id='input_2_170_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_170.6' id='input_2_170_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_2_171\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Billing Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    <div id='input_2_171_copy_values_option_container' class='copy_values_option_container' >\n                                        <input type='checkbox' id='input_2_171_copy_values_activated' class='copy_values_activated' value='1' data-source_field_id='170' name='input_171_copy_values_activated'  \/>\n                                        <label for='input_2_171_copy_values_activated' id='input_2_171_copy_values_option_label' class='copy_values_option_label inline gform-field-label gform-field-label--type-inline'>Same as Shipping Address<\/label>\n                                    <\/div>\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_2_171' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_171_1_container' >\n                                        <input type='text' name='input_171.1' id='input_2_171_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                        <label for='input_2_171_1' id='input_2_171_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_2_171_2_container' >\n                                        <input type='text' name='input_171.2' id='input_2_171_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/>\n                                        <label for='input_2_171_2' id='input_2_171_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_171_3_container' >\n                                    <input type='text' name='input_171.3' id='input_2_171_3' value=''    aria-required='true'   autocomplete=\"address-level2\" \/>\n                                    <label for='input_2_171_3' id='input_2_171_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_171_4_container' >\n                                        <select name='input_171.4' id='input_2_171_4'     aria-required='true'   autocomplete=\"address-level1\" ><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>\n                                        <label for='input_2_171_4' id='input_2_171_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_171_5_container' >\n                                    <input type='text' name='input_171.5' id='input_2_171_5' value=''    aria-required='true'   autocomplete=\"postal-code\" \/>\n                                    <label for='input_2_171_5' id='input_2_171_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_171.6' id='input_2_171_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_74' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_2_74' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_8' class='gform_page' data-js='page-field-id-74' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_133\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full nt-step-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Requested Rx<\/h2><\/div><div id=\"field_2_232\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full nt-step-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div style=\"background-color: #fff3cd; padding: 15px; border-radius: 5px; border: 1px solid #ffeeba; font-family: Arial, sans-serif; color: #856404;\">\n    <h3 style=\"margin-top: 0; color: #856404;\">Important Update on Tirzepatide<\/h3>\n    <p>Tirzepatide is no longer on the FDA shortage list and is now commercially available. Due to this, compounded Tirzepatide is no longer permitted.<\/p>\n    \n    <h3 style=\"margin-bottom: 5px; color: #856404;\">For Existing Patients:<\/h3>\n    <p>If you\u2019ve been successfully using Tirzepatide and wish to continue your treatment, we can still help you get the prescription you need. Contact us at \n        <a href=\"mailto:support@simplefixrx.com\" style=\"color: #856404; font-weight: bold;\">support@simplefixrx.com<\/a> \n        or text <strong>682-245-2031<\/strong>, and our team will guide you through your options.<\/p>\n<\/div><\/div><div id=\"field_2_190\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_190'>Pharmacy Routing - Luxe Med<\/label><div class='ginput_container ginput_container_select'><select name='input_190' id='input_2_190' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Pharmacy Routing - Luxe Med' >Pharmacy Routing - Luxe Med<\/option><option value='' selected='selected'><\/option><\/select><\/div><\/div><div id=\"field_2_211\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_211'>Pharmacy Routing - Elysium Pharmaceuticals<\/label><div class='ginput_container ginput_container_select'><select name='input_211' id='input_2_211' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Pharmacy Routing - Elysium Pharmaceuticals' >Pharmacy Routing - Elysium Pharmaceuticals<\/option><option value='' selected='selected'><\/option><\/select><\/div><\/div><div id=\"field_2_188\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_188'>Pharmacy Routing - Red Rock Springville<\/label><div class='ginput_container ginput_container_select'><select name='input_188' id='input_2_188' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Pharmacy Routing - Red Rock Springville' >Pharmacy Routing - Red Rock Springville<\/option><option value='' selected='selected'><\/option><\/select><\/div><\/div><div id=\"field_2_189\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_189'>Pharmacy Routing - Red Rock St George<\/label><div class='ginput_container ginput_container_select'><select name='input_189' id='input_2_189' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Pharmacy Routing - Red Rock St George' >Pharmacy Routing - Red Rock St George<\/option><option value='' selected='selected'><\/option><\/select><\/div><\/div><div id=\"field_2_213\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_213'>Pharmacy Routing - RxCompound Store - Ship Direct<\/label><div class='ginput_container ginput_container_select'><select name='input_213' id='input_2_213' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Pharmacy Routing - RxCompound Store - Ship Direct' >Pharmacy Routing - RxCompound Store - Ship Direct<\/option><option value='' ><\/option><\/select><\/div><\/div><div id=\"field_2_230\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_230'>Pharmacy Routing - Specialty Rx Care<\/label><div class='ginput_container ginput_container_select'><select name='input_230' id='input_2_230' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Pharmacy Routing - Specialty Rx Care' selected='selected'>Pharmacy Routing - Specialty Rx Care<\/option><option value='' ><\/option><\/select><\/div><\/div><fieldset id=\"field_2_212\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_price_2_212 gfield_product_2_212 gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label' >Product Options - Elysium Pharmaceuticals<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_212'>\n\t\t\t<div class='gchoice gchoice_2_212_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='2 mg \/ 0.5 mg Weekly Semaglutide - 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes - Patient Instructions: Inject 25 units weekly.|300'  id='choice_2_212_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_212_0' id='label_2_212_0' class='gform-field-label gform-field-label--type-inline'><strong>2 mg \/ 0.5 mg Weekly GLP-1<\/strong> - $300 \u20034 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_212_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='4 mg \/ 1.0 mg Weekly Semaglutide - 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes - Patient Instructions: Inject 25 units once weekly.|350'  id='choice_2_212_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_212_1' id='label_2_212_1' class='gform-field-label gform-field-label--type-inline'><strong>4 mg \/ 1.0 mg Weekly GLP-1<\/strong> - $350 \u20034 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_212_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='6 mg \/ 1.5 mg Weekly Semaglutide - 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes - Patient Instructions: Inject 25 units once weekly.|375'  id='choice_2_212_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_212_2' id='label_2_212_2' class='gform-field-label gform-field-label--type-inline'><strong>6 mg \/ 1.5 mg Weekly GLP-1<\/strong> - $375 \u20034 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_212_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='10 mg \/ 2.5 mg Weekly Semaglutide - 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes - Patient Instructions: Inject 25 units once weekly.|400'  id='choice_2_212_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_212_3' id='label_2_212_3' class='gform-field-label gform-field-label--type-inline'><strong>10 mg \/ 2.5 mg Weekly GLP-1<\/strong> - $400 \u20034 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_212_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='2 mg + 2 mg + 4 mg Weekly Semaglutide - 12 Injections, 12-Week Supply, 3x 1ml Vials + Double-Pack Syringes - Patient Instructions: Inject 25 units once weekly.|595'  id='choice_2_212_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_212_4' id='label_2_212_4' class='gform-field-label gform-field-label--type-inline'><strong>GLP-1 Starter Package<\/strong> - $595 \u20032 mg + 2 mg + 4 mg (3-Month Supply)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_212_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='4 mg + 6 mg + 10 mg Weekly Semaglutide - 12 Injections, 12-Week Supply, 3x 1ml Vials + Double-Pack Syringes - Patient Instructions: Inject 25 units once weekly.|795'  id='choice_2_212_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_212_5' id='label_2_212_5' class='gform-field-label gform-field-label--type-inline'><strong>GLP-1 Performance Package<\/strong> - $795 \u20034 mg + 6 mg + 10 mg (3-Month Supply)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_212_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='10 mg \/ 2.5 mg Weekly Semaglutide - 12 Injections, 12-Week Supply, 3x 1ml Vials + Double-Pack Syringes - Patient Instructions: Inject 25 units once weekly.|895'  id='choice_2_212_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_212_6' id='label_2_212_6' class='gform-field-label gform-field-label--type-inline'><strong>GLP-1 Max Package<\/strong> - $895 \u200310 mg + 10 mg + 10 mg (3-Month Supply)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_212_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='10 mg \/ 5 mg Weekly Tirzepatide - 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes - Patient Instructions: Inject 50 units once weekly.|390'  id='choice_2_212_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_212_7' id='label_2_212_7' class='gform-field-label gform-field-label--type-inline'><strong>10 mg per ml, 2ml vial, 20 mg total \/ 5 mg Weekly GLP-1\/GIP<\/strong> - $390 \u20034 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_212_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='15 mg \/ 7.5 mg Weekly Tirzepatide - 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes - Patient Instructions: Inject 50 units once weekly.|450'  id='choice_2_212_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_212_8' id='label_2_212_8' class='gform-field-label gform-field-label--type-inline'><strong>15 mg per ml, 2ml vial, 30 mg total \/ 7.5 mg Weekly GLP-1\/GIP<\/strong> - $450 \u20034 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_212_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='20 mg \/ 10 mg Weekly Tirzepatide - 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes - Patient Instructions: Inject 50 units once weekly.|525'  id='choice_2_212_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_212_9' id='label_2_212_9' class='gform-field-label gform-field-label--type-inline'><strong>20 mg per ml, 2ml vial, 40 mg total \/ 10 mg Weekly GLP-1\/GIP<\/strong> - $525 \u20034 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_212_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='25 mg \/ 12.5 mg Weekly Tirzepatide - 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes - Patient Instructions: Inject 50 units once weekly.|550'  id='choice_2_212_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_212_10' id='label_2_212_10' class='gform-field-label gform-field-label--type-inline'><strong>25 mg per ml, 2ml vial, 50 mg total \/ 12.5 mg Weekly GLP-1\/GIP<\/strong> - $550 \u20034 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_212_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='30 mg \/ 15 mg Weekly Tirzepatide - 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes - Patient Instructions: Inject 50 units once weekly.|625'  id='choice_2_212_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_212_11' id='label_2_212_11' class='gform-field-label gform-field-label--type-inline'><strong>30 mg per ml, 2ml vial, 60 mg total \/ 15 mg Weekly GLP-1\/GIP<\/strong> - $625 \u20034 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_212_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='10 mg + 10 mg + 15 mg Weekly Tirzepatide - 12 Injections, 12-Week Supply, 3x 2ml Vial + Single-Pack Syringes - Patient Instructions: Inject 50 units once weekly.|795'  id='choice_2_212_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_212_12' id='label_2_212_12' class='gform-field-label gform-field-label--type-inline'><strong>GLP-1\/GIP Starter Package<\/strong> - $795 \u200310 mg\/ml + 10 mg\/ml + 15 mg\/ml (3-Month Supply)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_212_13'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='20 mg + 25 mg + 30 mg Weekly Tirzepatide - 12 Injections, 12-Week Supply, 3x 2ml Vial + Single-Pack Syringes - Patient Instructions: Inject 50 units once weekly.|1250'  id='choice_2_212_13' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_212_13' id='label_2_212_13' class='gform-field-label gform-field-label--type-inline'><strong>GLP-1\/GIP Performance Package<\/strong> - $1250 \u200320 mg\/ml + 25 mg\/ml + 30 mg\/ml (3-Month Supply)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_212_14'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='30 mg \/ 15 mg Weekly Tirzepatide - 12 Injections, 12-Week Supply, 3x 2ml Vial + Single-Pack Syringes - Patient Instructions: Inject 50 units once weekly.|1450'  id='choice_2_212_14' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_212_14' id='label_2_212_14' class='gform-field-label gform-field-label--type-inline'><strong>GLP-1\/GIP Max Package<\/strong> - $1450 \u200330 mg\/ml + 30 mg\/ml + 30 mg\/ml (3-Month Supply)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_204\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_price_2_204 gfield_product_2_204 gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label' >Product Options - Red Rock<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_204'>\n\t\t\t<div class='gchoice gchoice_2_204_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_204' type='radio' value='0.5 mg GLP-1: 4 Injections, 4-Week Supply, 2.5mg\/1ml - Patient Instructions: 1ml vial inject 25 units weekly|300'  id='choice_2_204_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_204_0' id='label_2_204_0' class='gform-field-label gform-field-label--type-inline'><strong>0.5 mg GLP-1<\/strong> - $300 \u20034 Injections, 4-Week Supply, Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_204_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_204' type='radio' value='1.0 mg GLP-1: 4 Injections, 4-Week Supply, 2.5mg\/1ml - Patient Instructions: 2ml vial inject 50 units weekly|350'  id='choice_2_204_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_204_1' id='label_2_204_1' class='gform-field-label gform-field-label--type-inline'><strong>1.0 mg GLP-1<\/strong> - $350 \u20034 Injections, 4-Week Supply, Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_204_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_204' type='radio' value='1.0 mg GLP-1: 4 Injections, 4-Week Supply, 2.5mg\/1ml (2 refills) - Patient Instructions: 2ml vial inject 50 units weekly|795'  id='choice_2_204_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_204_2' id='label_2_204_2' class='gform-field-label gform-field-label--type-inline'><strong>1.0 mg GLP-1<\/strong> - $795 \u20034 Injections, 4-Week Supply, Single-Pack Syringes (2 refills)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_204_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_204' type='radio' value='1.7 mg GLP-1: 4 Injections, 4-Week Supply, 2.5mg\/1ml - Patient Instructions: 4ml vial inject 68 units weekly|375'  id='choice_2_204_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_204_3' id='label_2_204_3' class='gform-field-label gform-field-label--type-inline'><strong>1.7 mg GLP-1<\/strong> - $375 \u20034 Injections, 4-Week Supply, Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_204_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_204' type='radio' value='2.4 mg GLP-1: 4 Injections, 4-Week Supply, 2.5mg\/1ml - Patient Instructions: 4ml vial inject 90-100 units weekly|400'  id='choice_2_204_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_204_4' id='label_2_204_4' class='gform-field-label gform-field-label--type-inline'><strong>2.4 mg GLP-1<\/strong> - $400 \u20034 Injections, 4-Week Supply, Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_204_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_204' type='radio' value='2.4 mg GLP-1: 4 Injections, 4-Week Supply, 2.5mg\/1ml (2 refills) - Patient Instructions: 4ml vial inject 90-100 units weekly|995'  id='choice_2_204_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_204_5' id='label_2_204_5' class='gform-field-label gform-field-label--type-inline'><strong>2.4 mg GLP-1<\/strong> - $995 \u20034 Injections, 4-Week Supply, Single-Pack Syringes (2 refills)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_204_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_204' type='radio' value='GLP-1\/GIP 8.5mg-5mg\/ml Inject 50 units (4.25mg) subcutaneously every week for 4 weeks|390'  id='choice_2_204_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_204_6' id='label_2_204_6' class='gform-field-label gform-field-label--type-inline'><strong>4.25 mg GLP-1\/GIP<\/strong> - $390 \u20034 Injections, 4-Week Supply, Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_204_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_204' type='radio' value='GLP-1\/GIP 8.5mg-5mg\/ml Inject 75 units (6.375mg) subcutaneously every week for 4 weeks|450'  id='choice_2_204_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_204_7' id='label_2_204_7' class='gform-field-label gform-field-label--type-inline'><strong>6.375 mg GLP-1\/GIP<\/strong> - $450 \u20034 Injections, 4-Week Supply, Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_204_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_204' type='radio' value='GLP-1\/GIP 17mg-5mg\/ml Inject 50 units (8.5mg) subcutaneously every week for 4 weeks|525'  id='choice_2_204_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_204_8' id='label_2_204_8' class='gform-field-label gform-field-label--type-inline'><strong>8.5 mg GLP-1\/GIP<\/strong> - $525 \u20034 Injections, 4-Week Supply, Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_204_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_204' type='radio' value='GLP-1\/GIP 17mg-5mg\/ml Inject 64 units (11mg) subcutaneously every week for 4 weeks|550'  id='choice_2_204_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_204_9' id='label_2_204_9' class='gform-field-label gform-field-label--type-inline'><strong>11 mg GLP-1\/GIP<\/strong> - $550 \u20034 Injections, 4-Week Supply, Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_204_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_204' type='radio' value='GLP-1\/GIP 17mg-5mg\/ml Inject 80 units (13.5mg) subcutaneously every week for 4 weeks|625'  id='choice_2_204_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_204_10' id='label_2_204_10' class='gform-field-label gform-field-label--type-inline'><strong>13.5 mg GLP-1\/GIP<\/strong> - $625 \u20034 Injections, 4-Week Supply, Single-Pack Syringes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_215\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_price_2_215 gfield_product_2_215 gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label' >Product Options - Specialty Rx Care<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_215'>\n\t\t\t<div class='gchoice gchoice_2_215_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_215' type='radio' value='GLP1\/ 1 with Glycine 2.5mg \/ 5mg\/ml in 1 ml vial --------------- Directions 24 units of (0.6mg) Subcutaneous  weekly|300'  id='choice_2_215_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_215_0' id='label_2_215_0' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine 2.5mg \/ 5mg\/ml<\/strong> - $300<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_215_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_215' type='radio' value='GLP1\/ 1 with Glycine 3.75mg\/ 12.5mg  2.5 ml vial ---------------- 4 Injections, 4-Week Supply Directions inject 60 units (0.9 mg) subcutaneous weekly|350'  id='choice_2_215_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_215_1' id='label_2_215_1' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine 3.75mg\/ 12.5mg <\/strong> - $350 \u2003<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_215_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_215' type='radio' value='GLP1\/ 1 with Glycine 6.25mg\/ 12.5mg  2.5 ml vial ---------------- 4 Injections, 4-Week Supply, Directions inject 60 units (1.5mg) subcutaneous weekly|375'  id='choice_2_215_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_215_2' id='label_2_215_2' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine 6.25mg\/ 12.5mg<\/strong> - $375<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_215_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_215' type='radio' value='GLP1\/ 1 with Glycine 8.75mg\/ 17.5mg  3.5 ml vial ---------------- 4 Injections, 4-Week Supply Directions inject 80 units (2.0 mg) subcutaneous weekly|400'  id='choice_2_215_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_215_3' id='label_2_215_3' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine 8.75mg\/ 17.5mg<\/strong> - $400<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_215_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_215' type='radio' value='GLP1\/ GIP \/Glycine 20mg\/10mg in a 2ml vial Directions inject 45 units (4.5mg) SQ weekly|390'  id='choice_2_215_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_215_4' id='label_2_215_4' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP Glycine  20mg\/10mg<\/strong> - $390<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_215_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_215' type='radio' value='GLP1\/ GIP \/Glycine 30mg\/7.5mg in a 3ml Vial Inject 68 units (6.8mg) SQ weekly|450'  id='choice_2_215_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_215_5' id='label_2_215_5' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP \/Glycine 30mg\/ 7.5mg<\/strong> - $450<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_215_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_215' type='radio' value='GLP1\/ GIP \/Glycine 40mg\/10mg in a 2ml Vial ----  Directions inject 45 units (9mg) SQ weekly|525'  id='choice_2_215_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_215_6' id='label_2_215_6' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP \/Glycine 40mg\/10mg<\/strong> - $525<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_215_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_215' type='radio' value='GLP1\/ GIP \/Glycine 60mg\/15mg in a 3ml Vial -------Directions Inject 68 units (13.6mg) SQ weekly|550'  id='choice_2_215_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_215_7' id='label_2_215_7' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP \/Glycine 60mg\/15mg<\/strong> - $550<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_267\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_price_2_267 gfield_product_2_267 gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label' >Product Options - Specialty Rx Care - 1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_267'>\n\t\t\t<div class='gchoice gchoice_2_267_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='GLP1\/ 1 with Glycine 2.5mg \/ 5mg\/ml in 1 ml vial --------------- Directions 24 units of (0.6mg) Subcutaneous  weekly|300'  id='choice_2_267_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_267_0' id='label_2_267_0' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine 2.5mg \/ 5mg\/ml<\/strong> - $300<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_267_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='GLP1\/ 1 with Glycine 3.75mg\/ 12.5mg  2.5 ml vial ---------------- 4 Injections, 4-Week Supply Directions inject 60 units (0.9 mg) subcutaneous weekly|350'  id='choice_2_267_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_267_1' id='label_2_267_1' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine 3.75mg\/ 12.5mg <\/strong> - $350 \u2003<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_267_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='GLP1\/ 1 with Glycine 6.25mg\/ 12.5mg  2.5 ml vial ---------------- 4 Injections, 4-Week Supply, Directions inject 60 units (1.5mg) subcutaneous weekly|375'  id='choice_2_267_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_267_2' id='label_2_267_2' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine 6.25mg\/ 12.5mg<\/strong> - $375<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_267_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='GLP1\/ 1 with Glycine 8.75mg\/ 17.5mg  3.5 ml vial ---------------- 4 Injections, 4-Week Supply Directions inject 80 units (2.0 mg) subcutaneous weekly|400'  id='choice_2_267_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_267_3' id='label_2_267_3' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine 8.75mg\/ 17.5mg<\/strong> - $400<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_267_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='month 1 GLP 1\/ Glycine 2.5mg\/5mg\/ ml in 1ml vial Inject 24units (0.6mg) subcutaneous. month 2 GLP 1\/ Glycine 2.5mg\/5mg\/ ml in 1ml vial Inject 24units (0.6mg) subcutaneous. Month 3 GLP 1\/ glycine 3.75mg\/12.5mg in 2.5ml vial directions inject 60 units (0.9mg) subcutaneous weekly|595'  id='choice_2_267_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_267_4' id='label_2_267_4' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine Starter Package<\/strong> - $595<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_267_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='GLP1\/ 1 with Glycine 3.75mg\/ 12.5mg  2.5 ml vial \/Syringes Directions inject 60 units (0.9 mg) subcutaneous weekly Vial 2 GLP1\/ glycine 6.25mg\/ 12.5mg in 2.5ml vial directions Inject 60 units weekly Subcutaneous Vial 3 GLP1\/ Glycine 17.5 mg in 3.5 ml vial Inject 80 units weekly (2mg) subcuta|795'  id='choice_2_267_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_267_5' id='label_2_267_5' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine Performance Package<\/strong> - $795<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_267_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='GLP1\/ 1 with Glycine 8.75mg\/17.5mg in 3.5ml vial-------------- 12 injections, 12 Week Supply, Directions Inject 80 units (2mg) subcutaneous weekly|895'  id='choice_2_267_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_267_6' id='label_2_267_6' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine Max Package<\/strong> - $895<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_267_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='GLP1\/ GIP \/Glycine 20mg\/10mg in a 2ml vial Directions inject 45 units (4.5mg) SQ weekly|390'  id='choice_2_267_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_267_7' id='label_2_267_7' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP Glycine  20mg\/10mg<\/strong> - $390<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_267_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='GLP1\/ GIP \/Glycine 30mg\/7.5mg in a 3ml Vial Inject 68 units (6.8mg) SQ weekly|450'  id='choice_2_267_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_267_8' id='label_2_267_8' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP \/Glycine 30mg\/ 7.5mg<\/strong> - $450<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_267_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='GLP1\/ GIP \/Glycine 40mg\/10mg in a 2ml Vial ----  Directions inject 45 units (9mg) SQ weekly|525'  id='choice_2_267_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_267_9' id='label_2_267_9' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP \/Glycine 40mg\/10mg<\/strong> - $525<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_267_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='GLP1\/ GIP \/Glycine 60mg\/15mg in a 3ml Vial -------Directions Inject 68 units (13.6mg) SQ weekly|550'  id='choice_2_267_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_267_10' id='label_2_267_10' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP \/Glycine 60mg\/15mg<\/strong> - $550<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_267_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='GLP1\/ GIP with Glycine Starter Package - Month 1 4.5mg weekly, Month 2 4.5 mg weekly Month 3 6.8 mg weekly|795'  id='choice_2_267_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_267_11' id='label_2_267_11' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP with Glycine Starter Package<\/strong> - $795<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_267_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='GLP1\/ GIP with Glycine Performance Package - Vial 1 (6.8 mg) weekly, Vial 2 (9 mg) weekly Vial 3 (13.6mg) weekly Standard directions|1250'  id='choice_2_267_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_267_12' id='label_2_267_12' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP with Glycine Performance Package <\/strong> - $1250<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_267_13'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='GLP1\/ GIP with Glycine Max Package 3 month supply (ships monthly) GLP1\/ GIP 60mg\/Glycine 15mg in a 3ml Vial -------12 weeks Supply Directions Inject 68 units (13.6mg) SQ weekly 3 shipments|1450'  id='choice_2_267_13' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_267_13' id='label_2_267_13' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP with Glycine Max Package 3 month supply (ships monthly) GLP1\/ GIP 60mg\/Glycine 15mg <\/strong> - $1450<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_229\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_price_2_229 gfield_product_2_229 gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label' >Product Options - Specialty Rx Care<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_229'>\n\t\t\t<div class='gchoice gchoice_2_229_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_229' type='radio' value='GLP1\/ 1 with Glycine 2.5mg \/ 5mg\/ml in 1 ml vial --------------- Directions 24 units of (0.6mg) Subcutaneous  weekly|300'  id='choice_2_229_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_229_0' id='label_2_229_0' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine 2.5mg \/ 5mg\/ml <\/strong> - $300<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_229_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_229' type='radio' value='GLP1\/ 1 with Glycine 3.75mg\/ 12.5mg  2.5 ml vial ---------------- 4 Injections, 4-Week Supply Directions inject 60 units (0.9 mg) subcutaneous weekly|350'  id='choice_2_229_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_229_1' id='label_2_229_1' class='gform-field-label gform-field-label--type-inline'><strong>  GLP1\/ 1 with Glycine 3.75mg\/ 12.5mg <\/strong> - $350<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_229_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_229' type='radio' value='GLP1\/ 1 with Glycine 6.25mg\/ 12.5mg  2.5 ml vial ---------------- 4 Injections, 4-Week Supply, Directions inject 60 units (1.5mg) subcutaneous weekly|375'  id='choice_2_229_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_229_2' id='label_2_229_2' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine 6.25mg\/ 12.5mg <\/strong> - $375<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_229_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_229' type='radio' value='GLP1\/ 1 with Glycine 8.75mg\/ 17.5mg  3.5 ml vial ---------------- 4 Injections, 4-Week Supply Directions inject 80 units (2.0 mg) subcutaneous weekly|400'  id='choice_2_229_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_229_3' id='label_2_229_3' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine 8.75mg\/ 17.5mg  <\/strong> - $400<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_229_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_229' type='radio' value='GLP1\/ GIP \/Glycine 20mg\/10mg in a 2ml vial Directions inject 45 units (4.5mg) SQ weekly|390'  id='choice_2_229_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_229_4' id='label_2_229_4' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP Glycine  20mg\/10mg<\/strong> - $390<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_229_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_229' type='radio' value='GLP1\/ GIP \/Glycine 30mg\/7.5mg in a 3ml Vial Inject 68 units (6.8mg) SQ weekly|450'  id='choice_2_229_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_229_5' id='label_2_229_5' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP \/Glycine 30mg\/ 7.5mg<\/strong> - $450<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_229_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_229' type='radio' value='GLP1\/ GIP \/Glycine 40mg\/10mg in a 2ml Vial ---- 4 Injections, 4-Week Supply Directions inject 45 units (9mg) SQ weekly|525'  id='choice_2_229_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_229_6' id='label_2_229_6' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP \/Glycine 40mg\/10mg<\/strong> - $525<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_229_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_229' type='radio' value='GLP1\/ GIP \/Glycine 60mg\/15mg in a 3ml Vial ------- 4 Injections, 4-Week Supply Directions Inject 68 units (13.6mg) SQ weekly|550'  id='choice_2_229_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_229_7' id='label_2_229_7' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP \/Glycine 60mg\/15mg<\/strong> - $550<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_268\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_price_2_268 gfield_product_2_268 gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Product Options - Specialty Rx Care-<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_268'>\n\t\t\t<div class='gchoice gchoice_2_268_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_268' type='radio' value='GLP1\/ 1 with Glycine 2.5mg \/ 5mg\/ml in 1 ml vial --------------- Directions 24 units of (0.6mg) Subcutaneous weekly|200'  id='choice_2_268_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_268_0' id='label_2_268_0' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine 2.5mg \/ 5mg\/ml <\/strong> - $200<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_268_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_268' type='radio' value='GLP1\/ 1 with Glycine 3.75mg\/ 12.5mg  2.5 ml vial ---------------- 4 Injections, 4-Week Supply Directions inject 60 units (0.9 mg) subcutaneous weekly|250'  id='choice_2_268_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_268_1' id='label_2_268_1' class='gform-field-label gform-field-label--type-inline'><strong>  GLP1\/ 1 with Glycine 3.75mg\/ 12.5mg <\/strong> - $250<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_268_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_268' type='radio' value='GLP1\/ 1 with Glycine 6.25mg\/ 12.5mg  2.5 ml vial ---------------- 4 Injections, 4-Week Supply, Directions inject 60 units (1.5mg) subcutaneous weekly|350'  id='choice_2_268_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_268_2' id='label_2_268_2' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine 6.25mg\/ 12.5mg <\/strong> - $350<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_268_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_268' type='radio' value='GLP1\/ 1 with Glycine 8.75mg\/ 17.5mg  3.5 ml vial ---------------- 4 Injections, 4-Week Supply Directions inject 80 units (2.0 mg) subcutaneous weekly|375'  id='choice_2_268_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_268_3' id='label_2_268_3' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine 8.75mg\/ 17.5mg  <\/strong> - $375<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_268_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_268' type='radio' value='1 GLP 1\/ Glycine 2.5mg\/5mg\/ ml in 1ml vial --------------- Directions Inject 24units (0.6mg) subcutaneous. month 2  GLP 1\/ glycine 3.75mg\/12.5mg in 2.5ml vial --------------- Directions inject 60 units (0.9mg) subcutaneous weekly|350'  id='choice_2_268_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_268_4' id='label_2_268_4' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine Starter Package 2 month supply vial 1 (1.5mg\/5mg), vial 2 (3.75mg\/12.5mg)<\/strong> - $350<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_268_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_268' type='radio' value='GLP1\/ 1 with Glycine 3.75mg\/ 12.5mg  2.5 ml vial --------------- Directions inject 60 units (0.9 mg) subcutaneous weekly, Vial 2 GLP1\/ glycine 6.25mg\/ 12.5mg in 2.5ml vial --------------- Directions Inject 60 units subcutaneous weekly|400'  id='choice_2_268_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_268_5' id='label_2_268_5' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine Performance Package 2 month supply vial 1 (3.75\/12.5mg), vial 2 (6.25mg\/12.5mg)<\/strong> - $400<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_268_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_268' type='radio' value='GLP1\/ 1 with Glycine 8.75mg\/17.5mg in 3.5ml vial--------------  Directions Inject 80 units (2mg) subcutaneous weekly.    8 injections, 8 Week Supply,|450'  id='choice_2_268_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_268_6' id='label_2_268_6' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ 1 with Glycine Max Package 2 month supply (8.75mg\/17.5mg)<\/strong> - $450<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_268_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_268' type='radio' value='GLP1\/ GIP \/Glycine 20mg\/10mg in a 2ml vial Directions inject 45 units (4.5mg) SQ weekly|390'  id='choice_2_268_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_268_7' id='label_2_268_7' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP Glycine  20mg\/10mg<\/strong> - $390<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_268_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_268' type='radio' value='GLP1\/ GIP \/Glycine 30mg\/7.5mg in a 3ml Vial Inject 68 units (6.8mg) SQ weekly|450'  id='choice_2_268_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_268_8' id='label_2_268_8' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP \/Glycine 30mg\/ 7.5mg<\/strong> - $450<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_268_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_268' type='radio' value='GLP1\/ GIP \/Glycine 40mg\/10mg in a 2ml Vial ---- 4 Injections, 4-Week Supply Directions inject 45 units (9mg) SQ weekly|525'  id='choice_2_268_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_268_9' id='label_2_268_9' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP \/Glycine 40mg\/10mg<\/strong> - $525<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_268_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_268' type='radio' value='GLP1\/ GIP \/Glycine 60mg\/15mg in a 3ml Vial ------- 4 Injections, 4-Week Supply Directions Inject 68 units (13.6mg) SQ weekly|550'  id='choice_2_268_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_268_10' id='label_2_268_10' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP \/Glycine 60mg\/15mg<\/strong> - $550<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_268_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_268' type='radio' value='GLP1\/ GIP with Glycine Starter Package - Month 1 (4.5mg) weekly, Month 2 (6.8 mg) weekly standard directions for each|650'  id='choice_2_268_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_268_11' id='label_2_268_11' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP with Glycine Starter Package 2 month supply vial 1 (14.5mg), vial 2 (6.8mg)<\/strong> - $650<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_268_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_268' type='radio' value='GLP1\/ GIP with Glycine Performance Package - Vial 1 (9 mg) weekly, Vial 2 (13.6 mg) weekly Standard directions|825'  id='choice_2_268_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_268_12' id='label_2_268_12' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP with Glycine Performance Package 2 month supply vial 1 (9mg), vial 2 (13.6mg)<\/strong> - $825<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_268_13'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_268' type='radio' value='GLP1\/ GIP with Glycine Max Package 2 months of (13.6mg) standard directions|900'  id='choice_2_268_13' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_268_13' id='label_2_268_13' class='gform-field-label gform-field-label--type-inline'><strong>GLP1\/ GIP with Glycine Max Package 2 month supply (GLP1\/ GIP 60mg\/Glycine 13.6mg)<\/strong> - $900<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_177\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_price_2_177 gfield_product_2_177 gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label' >Product Options - Luxe<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_177'>\n\t\t\t<div class='gchoice gchoice_2_177_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='0.5 mg GLP-1\/cyanocobalamin: 4 Injections, 4-Week Supply, .5mg\/1mg\/ml 3ml single vial + Single-Pack Syringes - Patient Instructions: Weeks 1 &amp; 2, inject 40 units weekly; Weeks 3 &amp; 4, inject 75 units weekly.|300'  id='choice_2_177_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_177_0' id='label_2_177_0' class='gform-field-label gform-field-label--type-inline'><strong>0.5 mg GLP-1<\/strong> - $300 \u20034 Injections, 4-Week Supply, 1x 3ml Vial + Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_177_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='1.0 mg GLP-1\/cyanocobalamin: 4 Injections, 4-Week Supply, 1.0mg\/1mg\/ml 3ml single vial + Single-Pack Syringes - Patient Instructions: Inject 75 units once weekly.|350'  id='choice_2_177_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_177_1' id='label_2_177_1' class='gform-field-label gform-field-label--type-inline'><strong>1.0 mg GLP-1<\/strong> - $350 \u20034 Injections, 4-Week Supply, 1x 3ml Vial + Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_177_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='1.0 mg GLP-1\/cyanocobalamin: 12 Injections, 12-Week Supply, 1.0mg\/1mg\/ml 3ml (3 vials total) + Double-Pack Syringes - Patient Instructions: Inject 75 units once weekly.|795'  id='choice_2_177_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_177_2' id='label_2_177_2' class='gform-field-label gform-field-label--type-inline'><strong>1.0 mg GLP-1<\/strong> - $795 \u200312 Injections, 12-Week Supply, 3x 3ml Vials + Double-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_177_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='1.7 mg GLP-1\/cyanocobalamin: 4 Injections, 4-Week Supply, 1.7mg\/1mg\/ml 3ml single vial + Single-Pack Syringes - Patient Instructions: Inject 75 units once weekly.|375'  id='choice_2_177_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_177_3' id='label_2_177_3' class='gform-field-label gform-field-label--type-inline'><strong>1.7 mg GLP-1<\/strong> - $375 \u20034 Injections, 4-Week Supply, 1x 3ml Vial + Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_177_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='2.4 mg GLP-1\/cyanocobalamin: 4 Injections, 4-Week Supply, 2.4mg\/1mg\/ml 3ml single vial + Single-Pack Syringes - Patient Instructions: Inject 75 units once weekly.|400'  id='choice_2_177_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_177_4' id='label_2_177_4' class='gform-field-label gform-field-label--type-inline'><strong>2.4 mg GLP-1<\/strong> - $400 \u20034 Injections, 4-Week Supply, 1x 3ml Vial + Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_177_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='2.4 mg GLP-1\/cyanocobalamin: 12 Injections, 12-Week Supply, 2.4mg\/1mg\/ml 3ml (3 vials total) + Double-Pack Syringes - Patient Instructions: Inject 75 units once weekly.|995'  id='choice_2_177_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_177_5' id='label_2_177_5' class='gform-field-label gform-field-label--type-inline'><strong>2.4 mg GLP-1<\/strong> - $995 \u200312 Injections, 12-Week Supply, 3x 3ml Vials + Double-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_177_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='5 mg - GLP-1\/GIP-5MG\/B12 0.25MG\/0.75ML INJ SOL 3ML: 4 Injections, 4-Week Supply + Single-Pack Syringes - Patient Instructions: Inject 75 units once weekly.|390'  id='choice_2_177_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_177_6' id='label_2_177_6' class='gform-field-label gform-field-label--type-inline'><strong>5 mg GLP-1\/GIP<\/strong> - $390 \u20034 Injections, 4-Week Supply, 1x 3ml Vial + Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_177_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='5 mg - GLP-1\/GIP-15MG\/B12 0.25MG\/0.75ML INJ SOL 3ML: 12 Injections, 12-Week Supply + Double-Pack Syringes - Patient Instructions: Inject 25 units once weekly.|795'  id='choice_2_177_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_177_7' id='label_2_177_7' class='gform-field-label gform-field-label--type-inline'><strong>5 mg\/15 mg GLP-1\/GIP<\/strong> - $795 \u200312 Injections, 12-Week Supply, 1x 3ml Vial + Double-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_177_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='7.5 mg-  GLP-1\/GIP-7.5MG\/B12 0.25MG\/0.75ML INJ SOL 3ML: 4 Injections, 4-Week Supply + Single-Pack Syringes - Patient Instructions: Inject 75 units once weekly.|450'  id='choice_2_177_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_177_8' id='label_2_177_8' class='gform-field-label gform-field-label--type-inline'><strong>7.5 mg GLP-1\/GIP<\/strong> - $450 \u20034 Injections, 4-Week Supply, 1x 3ml Vial + Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_177_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='10 mg - GLP-1\/GIP-10MG\/B12 0.25MG\/0.75ML INJ SOL 3ML: 4 Injections, 4-Week Supply + Single-Pack Syringes - Patient Instructions: Inject 75 units once weekly.|525'  id='choice_2_177_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_177_9' id='label_2_177_9' class='gform-field-label gform-field-label--type-inline'><strong>10 mg GLP-1\/GIP<\/strong> - $525 \u20034 Injections, 4-Week Supply, 1x 3ml Vial + Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_177_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='12.5 mg - GLP-1\/GIP-12.5MG\/B12 0.25MG\/0.75ML INJ SOL 3ML: 4 Injections, 4-Week Supply + Single-Pack Syringes - Patient Instructions: Inject 75 units once weekly.|550'  id='choice_2_177_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_177_10' id='label_2_177_10' class='gform-field-label gform-field-label--type-inline'><strong>12.5 mg GLP-1\/GIP<\/strong> - $550 \u20034 Injections, 4-Week Supply, 1x 3ml Vial + Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_177_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='15 mg - GLP-1\/GIP-15MG\/B12 0.25MG\/0.75ML INJ SOL 3ML: 4 Injections, 4-Week Supply + Single-Pack Syringes - Patient Instructions: Inject 75 units once weekly.|625'  id='choice_2_177_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_177_11' id='label_2_177_11' class='gform-field-label gform-field-label--type-inline'><strong>15 mg GLP-1\/GIP<\/strong> - $625 \u20034 Injections, 4-Week Supply, 1x 3ml Vial + Single-Pack Syringes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_177_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='5 mg - GLP-1\/GIP-15MG\/B12 0.25MG\/0.75ML INJ SOL 3ML: 12 Injections, 12-Week Supply + Double-Pack Syringes - Patient Instructions: Inject 25 units once weekly.|795'  id='choice_2_177_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_177_12' id='label_2_177_12' class='gform-field-label gform-field-label--type-inline'><strong>5 mg\/15 mg GLP-1\/GIP<\/strong> - $795 \u200312 Injections, 12-Week Supply, 1x 3ml Vial + Double-Pack Syringes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_180' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_2_180' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_9' class='gform_page' data-js='page-field-id-180' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_184\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full nt-step-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Available Add-ons (Optional)<\/h2><\/div><fieldset id=\"field_2_251\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Anti-Nausea Medication<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_251'><div class='gchoice gchoice_2_251_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_251.1' type='checkbox'  value='$30'  id='choice_2_251_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_251_1' id='label_2_251_1' class='gform-field-label gform-field-label--type-inline'><strong>4 mg Ondansetron<\/strong> - $30 \u2003Anti-Nausea Pills, 30-Count<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_260\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_price_2_260 gfield_product_2_260 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Anti-Nausea Medication<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_260'>\n\t\t\t<div class='gchoice gchoice_2_260_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_260' type='radio' value='&lt;strong&gt;4 mg Ondansetron&lt;\/strong&gt; Anti-Nausea Pills, 30-Count|30'  id='choice_2_260_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_260_0' id='label_2_260_0' class='gform-field-label gform-field-label--type-inline'><strong>4 mg Ondansetron<\/strong> - $30 \u2003Anti-Nausea Pills, 30-Count<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_261\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_price_2_261 gfield_product_2_261 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >B12<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_261'>\n\t\t\t<div class='gchoice gchoice_2_261_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_261' type='radio' value='&lt;strong&gt;B12&lt;\/strong&gt; one month supply IM|79'  id='choice_2_261_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_261_0' id='label_2_261_0' class='gform-field-label gform-field-label--type-inline'><strong>B12<\/strong> - $79 one month supply IM<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_263\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_price_2_263 gfield_product_2_263 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label' >Phentermine<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_263'>\n\t\t\t<div class='gchoice gchoice_2_263_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_263' type='radio' value='&lt;strong&gt;Phentermine 37.5 mg &lt;\/strong&gt; - 30-Count, $99|99'  id='choice_2_263_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_263_0' id='label_2_263_0' class='gform-field-label gform-field-label--type-inline'><strong>Phentermine 37.5 mg <\/strong> - 30-Count, $99<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_263_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_263' type='radio' value='&lt;strong&gt;Phentermine 37.5 mg &lt;\/strong&gt; -  60-Count,   $127|127'  id='choice_2_263_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_263_1' id='label_2_263_1' class='gform-field-label gform-field-label--type-inline'><strong>Phentermine 37.5 mg <\/strong> -  60-Count,   $127<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_263_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_263' type='radio' value='&lt;strong&gt;Phentermine 37.5 mg &lt;\/strong&gt; -  90-Count,   $155|155'  id='choice_2_263_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_263_2' id='label_2_263_2' class='gform-field-label gform-field-label--type-inline'><strong>Phentermine 37.5 mg <\/strong> -  90-Count,   $155<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_262\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_price_2_262 gfield_product_2_262 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >NAD - Anti-Aging<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_262'>\n\t\t\t<div class='gchoice gchoice_2_262_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_262' type='radio' value='&lt;strong&gt;NAD&lt;\/strong&gt; - monthly|185'  id='choice_2_262_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_262_0' id='label_2_262_0' class='gform-field-label gform-field-label--type-inline'><strong>NAD<\/strong> $185\/ - monthly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_262_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_262' type='radio' value='&lt;strong&gt;NAD&lt;\/strong&gt; - 2 months|320'  id='choice_2_262_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_262_1' id='label_2_262_1' class='gform-field-label gform-field-label--type-inline'><strong>NAD<\/strong> $320\/ - 2 months<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_252\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >B12<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_252'><div class='gchoice gchoice_2_252_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_252.1' type='checkbox'  value='&lt;strong&gt;B12&lt;\/strong&gt; - $79 one month supply IM'  id='choice_2_252_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_252_1' id='label_2_252_1' class='gform-field-label gform-field-label--type-inline'><strong>B12<\/strong> - $79 one month supply IM<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_253\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Phentermine<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_253'><div class='gchoice gchoice_2_253_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_253.1' type='checkbox'  value='&lt;strong&gt;Phentermine 37.5 mg &lt;\/strong&gt; - 30-Count, $99'  id='choice_2_253_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_253_1' id='label_2_253_1' class='gform-field-label gform-field-label--type-inline'><strong>Phentermine 37.5 mg <\/strong> - 30-Count, $99<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_253_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_253.2' type='checkbox'  value='&lt;strong&gt;Phentermine 37.5 mg &lt;\/strong&gt; -  60-Count,   $127'  id='choice_2_253_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_253_2' id='label_2_253_2' class='gform-field-label gform-field-label--type-inline'><strong>Phentermine 37.5 mg <\/strong> -  60-Count,   $127<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_253_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_253.3' type='checkbox'  value='&lt;strong&gt;Phentermine 37.5 mg &lt;\/strong&gt; -  90-Count,   $155'  id='choice_2_253_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_253_3' id='label_2_253_3' class='gform-field-label gform-field-label--type-inline'><strong>Phentermine 37.5 mg <\/strong> -  90-Count,   $155<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_255\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >NAD - Anti-Aging<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_255'><div class='gchoice gchoice_2_255_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_255.1' type='checkbox'  value='&lt;strong&gt;NAD&lt;\/strong&gt; $185\/ - monthly'  id='choice_2_255_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_255_1' id='label_2_255_1' class='gform-field-label gform-field-label--type-inline'><strong>NAD<\/strong> $185\/ - monthly<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_255_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_255.2' type='checkbox'  value='&lt;strong&gt;NAD&lt;\/strong&gt; $320\/ - 2 months'  id='choice_2_255_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_255_2' id='label_2_255_2' class='gform-field-label gform-field-label--type-inline'><strong>NAD<\/strong> $320\/ - 2 months<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_198\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_2_218\" class=\"gfield gfield--type-quantity gfield--input-type-select gfield--width-half gfield_price gfield_price_2_219 gfield_quantity gfield_quantity_2_219 field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_218'>Quantity - Hydration Honey PM Moisturizer<\/label><div class='gfield_description' id='gfield_description_2_218'><h2 style=\"color:#f8238b;\">Hydration Honey PM Moisturizer<\/h2><br><\/div><div class='ginput_container ginput_container_select'><select name='input_218' id='input_2_218' class='medium gfield_select'  aria-describedby=\"gfield_description_2_218\"   aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Quantity<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><\/select><\/div><\/div><div id=\"field_2_219\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield--width-half gfield_price gfield_price_2_219 gfield_product_2_219 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_2_219_1'>Hydration Honey PM Moisturizer<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_219.1' value='Hydration Honey PM Moisturizer' class='gform_hidden' \/>\n\t\t\t\t\t<div id='ginput_product_price_2_219' class='ginput_product_price_wrapper'>\n\t\t\t\t\t\t<label for='ginput_base_price_2_219' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_219.2' class='ginput_product_price gform-text-input-reset' id='ginput_base_price_2_219' value='$41.00' aria-describedby=\"gfield_description_2_219\" \/>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t<\/div><div class='gfield_description' id='gfield_description_2_219'><p>Crafted in small batches from all-natural products. This is unlike any skincare on the market. Beeswax locks in moisture while preventing acne due to its natural antibacterial and antifungal properties. Propolis also locks in moisture and is used for wound healing in Europe. You will see a difference in your skin after you sleep in this!<\/p>\n<p>Instructions: Use nightly or as needed. <\/p>\n<p>*Use at night. Rub everywhere. Yes, we said it...Everywhere. Feel amazing in the morning.<\/p>\n<p>60 ml<\/p>\n<p>Ingredients: Beeswax, Propolis, Vitamin A, Cermides, Glycolic acid, Lactic acids, Salicylic acid, Hyaluronic Acid, Lavendar oil, Olive Oil, Shea Butter, Silica<\/p><\/div><\/div><div id=\"field_2_200\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_2_220\" class=\"gfield gfield--type-quantity gfield--input-type-select gfield--width-half gfield_price gfield_price_2_221 gfield_quantity gfield_quantity_2_221 field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_220'>Quantity - Royal Hive Anti-Aging Body Oil<\/label><div class='gfield_description' id='gfield_description_2_220'><h2 style=\"color:#f8238b;\">Royal Hive Anti-Aging Body Oil<\/h2><br><\/div><div class='ginput_container ginput_container_select'><select name='input_220' id='input_2_220' class='medium gfield_select'  aria-describedby=\"gfield_description_2_220\"   aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Quantity<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><\/select><\/div><\/div><div id=\"field_2_221\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield--width-half gfield_price gfield_price_2_221 gfield_product_2_221 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_2_221_1'>Royal Hive Anti-Aging Body Oil<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_221.1' value='Royal Hive Anti-Aging Body Oil' class='gform_hidden' \/>\n\t\t\t\t\t<div id='ginput_product_price_2_221' class='ginput_product_price_wrapper'>\n\t\t\t\t\t\t<label for='ginput_base_price_2_221' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_221.2' class='ginput_product_price gform-text-input-reset' id='ginput_base_price_2_221' value='$19.00' aria-describedby=\"gfield_description_2_221\" \/>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t<\/div><div class='gfield_description' id='gfield_description_2_221'><p>This luxurious body oil can double as a perfume. Only all-natural oils with a heavenly scent will soothe the skin, leaving you feeling like royalty for hours and hours. Created with:<\/p> <p>Vitamin E, almond oil, olive oil, castor oil, and fragrance.<\/p><\/div><\/div><div id=\"field_2_231\" class=\"gfield gfield--type-option gfield--input-type-select gfield--width-full gfield_price gfield_price_2_221 gfield_option_2_221 gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_231'>Size Options<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_231' id='input_2_231' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Travel Size|0' >Travel Size<\/option><option value='Medium|15' >Medium<\/option><option value='Full Size|40' >Full Size<\/option><\/select><\/div><\/div><div id=\"field_2_205\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_2_206\" class=\"gfield gfield--type-quantity gfield--input-type-select gfield--width-half gfield_price gfield_price_2_207 gfield_quantity gfield_quantity_2_207 field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_206'>Quantity - Royal Hive Daily Moisturize with Zinc Oxide<\/label><div class='gfield_description' id='gfield_description_2_206'><h2 style=\"color:#f8238b;\">Royal Hive Daily Moisturize with Zinc Oxide<\/h2><br><\/div><div class='ginput_container ginput_container_select'><select name='input_206' id='input_2_206' class='medium gfield_select'  aria-describedby=\"gfield_description_2_206\"   aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Quantity<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><\/select><\/div><\/div><div id=\"field_2_207\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield--width-half gfield_price gfield_price_2_207 gfield_product_2_207 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_2_207_1'>Royal Hive Daily Moisturize with Zinc Oxide<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_207.1' value='Royal Hive Daily Moisturize with Zinc Oxide' class='gform_hidden' \/>\n\t\t\t\t\t<div id='ginput_product_price_2_207' class='ginput_product_price_wrapper'>\n\t\t\t\t\t\t<label for='ginput_base_price_2_207' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_207.2' class='ginput_product_price gform-text-input-reset' id='ginput_base_price_2_207' value='$41.00' aria-describedby=\"gfield_description_2_207\" \/>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t<\/div><div class='gfield_description' id='gfield_description_2_207'><p>Beeswax, salicylic acid, hyaluronic acid, vitamin E, shea butter, glycolic acid, lactic acid, propolis, olive oil, ceramides, vitamin C, ferulic acid, and zinc oxide (mineral sunscreen).<\/p><\/div><\/div><div id=\"field_2_208\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_2_209\" class=\"gfield gfield--type-quantity gfield--input-type-select gfield--width-half gfield_price gfield_price_2_210 gfield_quantity gfield_quantity_2_210 field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_209'>Quantity - Royal Honeycomb Body and Hair Smoothing Balm<\/label><div class='gfield_description' id='gfield_description_2_209'><h2 style=\"color:#f8238b;\">Royal Honeycomb Body and Hair Smoothing Balm<\/h2><br><\/div><div class='ginput_container ginput_container_select'><select name='input_209' id='input_2_209' class='medium gfield_select'  aria-describedby=\"gfield_description_2_209\"   aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Quantity<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><\/select><\/div><\/div><div id=\"field_2_210\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield--width-half gfield_price gfield_price_2_210 gfield_product_2_210 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_2_210_1'>Royal Honeycomb Body and Hair Smoothing Balm<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_210.1' value='Royal Honeycomb Body and Hair Smoothing Balm' class='gform_hidden' \/>\n\t\t\t\t\t<div id='ginput_product_price_2_210' class='ginput_product_price_wrapper'>\n\t\t\t\t\t\t<label for='ginput_base_price_2_210' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_210.2' class='ginput_product_price gform-text-input-reset' id='ginput_base_price_2_210' value='$37.00' aria-describedby=\"gfield_description_2_210\" \/>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t<\/div><div class='gfield_description' id='gfield_description_2_210'><p>A hair balm made from Shea Butter, Almond Oil, Beeswax, and Signature Royal Hive Fragrance.<\/p><\/div><\/div><div id=\"field_2_225\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_2_226\" class=\"gfield gfield--type-quantity gfield--input-type-select gfield--width-half gfield_price gfield_price_2_227 gfield_quantity gfield_quantity_2_227 field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_226'>Quantity - Anti Acne Facial Polish<\/label><div class='gfield_description' id='gfield_description_2_226'><h2 style=\"color:#f8238b;\">Anti Acne Facial Polish<\/h2><br><\/div><div class='ginput_container ginput_container_select'><select name='input_226' id='input_2_226' class='medium gfield_select'  aria-describedby=\"gfield_description_2_226\"   aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Quantity<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><\/select><\/div><\/div><div id=\"field_2_227\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield--width-half gfield_price gfield_price_2_227 gfield_product_2_227 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_2_227_1'>Anti Acne Facial Polish<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_227.1' value='Anti Acne Facial Polish' class='gform_hidden' \/>\n\t\t\t\t\t<div id='ginput_product_price_2_227' class='ginput_product_price_wrapper'>\n\t\t\t\t\t\t<label for='ginput_base_price_2_227' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_227.2' class='ginput_product_price gform-text-input-reset' id='ginput_base_price_2_227' value='$12.00' aria-describedby=\"gfield_description_2_227\" \/>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t<\/div><div class='gfield_description' id='gfield_description_2_227'><p>All-natural facial soap that comes in a mesh hanging bag. Keep the product in the mesh even when using (it helps create lather and keeps it clean!). If you want clear skin with zero chemicals, then this product is for you.<\/p><\/div><\/div><div id=\"field_2_193\" class=\"gfield gfield--type-quantity gfield--input-type-select gfield--width-half gfield_price gfield_price_2_195 gfield_quantity gfield_quantity_2_195 field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_193'>Quantity - Hydration Honey Decolletage<\/label><div class='gfield_description' id='gfield_description_2_193'><h2 style=\"color:#f8238b;\">Hydration Honey Decolletage<\/h2><br><\/div><div class='ginput_container ginput_container_select'><select name='input_193' id='input_2_193' class='medium gfield_select'  aria-describedby=\"gfield_description_2_193\"   aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Quantity<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><\/select><\/div><\/div><div id=\"field_2_195\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield--width-half gfield_price gfield_price_2_195 gfield_product_2_195 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_2_195_1'>DISCONTINUED - Hydration Honey Decolletage* Face, neck, chest<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_195.1' value='DISCONTINUED - Hydration Honey Decolletage* Face, neck, chest' class='gform_hidden' \/>\n\t\t\t\t\t<div id='ginput_product_price_2_195' class='ginput_product_price_wrapper'>\n\t\t\t\t\t\t<label for='ginput_base_price_2_195' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_195.2' class='ginput_product_price gform-text-input-reset' id='ginput_base_price_2_195' value='$34.00' aria-describedby=\"gfield_description_2_195\" \/>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t<\/div><div class='gfield_description' id='gfield_description_2_195'><p>Crafted in small batches from all natural products. This is unlike any skincare on the market. Beeswax locks in moisture while preventing acne due to it's natural antibacterial, antifungal properties. We promise this is unlike other skincare product!<\/p>\n<p>Instructions: Use nightly or as needed. <\/p>\n<p>*Use at night. Rub everywhere. Yes, we said it...Everywhere. Feel amazing in the morning.<\/p>\n<p>60 ml<\/p>\n<p>Ingredients: Beeswax, Propolis, Vitamin A, Cermides, Glycolic acid, Lactic acids, Salicylic acid, Hyaluronic Acid, Lavendar oil, Olive Oil, Shea Butter, Silica<\/p><\/div><\/div><div id=\"field_2_196\" class=\"gfield gfield--type-quantity gfield--input-type-select gfield--width-half gfield_price gfield_price_2_197 gfield_quantity gfield_quantity_2_197 field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_196'>Quantity - Hydration Honey Body<\/label><div class='gfield_description' id='gfield_description_2_196'><h2 style=\"color:#f8238b;\">Hydration Honey Body<\/h2><br><\/div><div class='ginput_container ginput_container_select'><select name='input_196' id='input_2_196' class='medium gfield_select'  aria-describedby=\"gfield_description_2_196\"   aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Quantity<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><\/select><\/div><\/div><div id=\"field_2_197\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield--width-half gfield_price gfield_price_2_197 gfield_product_2_197 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_2_197_1'>DISCONTINUED - Hydration Honey Body<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_197.1' value='DISCONTINUED - Hydration Honey Body' class='gform_hidden' \/>\n\t\t\t\t\t<div id='ginput_product_price_2_197' class='ginput_product_price_wrapper'>\n\t\t\t\t\t\t<label for='ginput_base_price_2_197' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_197.2' class='ginput_product_price gform-text-input-reset' id='ginput_base_price_2_197' value='$39.00' aria-describedby=\"gfield_description_2_197\" \/>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t<\/div><div class='gfield_description' id='gfield_description_2_197'><p>Crafted in small batches from all natural products. This is unlike any skincare on the market. Beeswax locks in moisture while preventing acne due to it's natural antibacterial, antifungal properties. We promise this is unlike other skincare product!<\/p>\n<p>Use at night. Rub everywhere. Yes, we said it...Everywhere. Feel amazing in the morning.<\/p>\n<p>120ml <\/p>\n<p>Ingredients: Beeswax, Propolis, Vitamin A, Cermides, Glycolic Acid, Lactic Acids, Salicylic Acid, Hyaluronic Acid, Lavendar oil, Olive Oil, Shea Butter, Silica<\/p><\/div><\/div><div id=\"field_2_201\" class=\"gfield gfield--type-quantity gfield--input-type-select gfield--width-half gfield_price gfield_price_2_202 gfield_quantity gfield_quantity_2_202 field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_201'>Quantity - Blending Nectar Foundation<\/label><div class='gfield_description' id='gfield_description_2_201'><h2 style=\"color:#f8238b;\">Blending Nectar Foundation<\/h2><br><\/div><div class='ginput_container ginput_container_select'><select name='input_201' id='input_2_201' class='medium gfield_select'  aria-describedby=\"gfield_description_2_201\"   aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Quantity<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><\/select><\/div><\/div><div id=\"field_2_202\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield--width-half gfield_price gfield_price_2_202 gfield_product_2_202 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_2_202_1'>DISCONTINUED - Blending Nectar Foundation<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_202.1' value='DISCONTINUED - Blending Nectar Foundation' class='gform_hidden' \/>\n\t\t\t\t\t<div id='ginput_product_price_2_202' class='ginput_product_price_wrapper'>\n\t\t\t\t\t\t<label for='ginput_base_price_2_202' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_202.2' class='ginput_product_price gform-text-input-reset' id='ginput_base_price_2_202' value='$39.00' aria-describedby=\"gfield_description_2_202\" \/>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t<\/div><div class='gfield_description' id='gfield_description_2_202'><p>Skincare in a makeup? Yes, exactly! This combo has all the acids, sunscreen, silica (no caking) plus mineral color. You can thank us later!<\/p>\n<p>15ml Jar with cosmetic spatula<\/p>\n<p>Colors: Light\/Med, Med Dark, Dark<\/p><\/div><\/div><div id=\"field_2_203\" class=\"gfield gfield--type-option gfield--input-type-select gfield--width-full gfield_price gfield_price_2_202 gfield_option_2_202 gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_203'>Color Selection<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_203' id='input_2_203' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Color Options<\/option><option value='Light\/ Med|0' >Light\/ Med<\/option><option value='Med Dark|0' >Med Dark<\/option><option value='Dark|0' >Dark<\/option><\/select><\/div><\/div><div id=\"field_2_222\" class=\"gfield gfield--type-quantity gfield--input-type-select gfield--width-half gfield_price gfield_price_2_223 gfield_quantity gfield_quantity_2_223 field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_222'>Quantity - Blending Nectar Tinted SPF Liquid<\/label><div class='gfield_description' id='gfield_description_2_222'><h2 style=\"color:#f8238b;\">Blending Nectar Tinted SPF Liquid<\/h2><br><\/div><div class='ginput_container ginput_container_select'><select name='input_222' id='input_2_222' class='medium gfield_select'  aria-describedby=\"gfield_description_2_222\"   aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Quantity<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><\/select><\/div><\/div><div id=\"field_2_223\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield--width-half gfield_price gfield_price_2_223 gfield_product_2_223 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_2_223_1'>DISCONTINUED - Blending Nectar Tinted SPF Liquid<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_223.1' value='DISCONTINUED - Blending Nectar Tinted SPF Liquid' class='gform_hidden' \/>\n\t\t\t\t\t<div id='ginput_product_price_2_223' class='ginput_product_price_wrapper'>\n\t\t\t\t\t\t<label for='ginput_base_price_2_223' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_223.2' class='ginput_product_price gform-text-input-reset' id='ginput_base_price_2_223' value='$39.00' aria-describedby=\"gfield_description_2_223\" \/>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t<\/div><div class='gfield_description' id='gfield_description_2_223'><p>Guys, this one is for you too! Natural mineral sunscreen SPF 30, silica (no caking) plus mineral color. Available in 3 shades. You can thank us later!<\/p><p>15ml Jar with cosmetic spatula<\/p>\n<p>Colors: Light\/Med, Med Dark, Dark<\/p><\/div><\/div><div id=\"field_2_224\" class=\"gfield gfield--type-option gfield--input-type-select gfield--width-full gfield_price gfield_price_2_223 gfield_option_2_223 gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_224'>Color Selection<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_224' id='input_2_224' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Color Options<\/option><option value='Light\/ Med|0' >Light\/ Med<\/option><option value='Med Dark|0' >Med Dark<\/option><option value='Dark|0' >Dark<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_183' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_2_183' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_10' class='gform_page' data-js='page-field-id-183' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_130\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full nt-step-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Shipping Options<\/h2><\/div><div id=\"field_2_146\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h5>Please allow 4 days (48 hours for the physician, 48 hours for the pharmacy) to review and process your order.<\/h5><\/div><fieldset id=\"field_2_154\" class=\"gfield gfield--type-shipping gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_shipping gfield_shipping_2 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Shipping<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_154'>\n\t\t\t<div class='gchoice gchoice_2_154_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Standard Shipping|35'  id='choice_2_154_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_154\"   \/>\n\t\t\t\t\t<label for='choice_2_154_0' id='label_2_154_0' class='gform-field-label gform-field-label--type-inline'>Standard Shipping<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_154_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Standard Shipping with Insurance|45'  id='choice_2_154_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_154_1' id='label_2_154_1' class='gform-field-label gform-field-label--type-inline'>Standard Shipping with Insurance<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_2_154'>SimpleFixRx is not liable for packages lost or stolen during transit. Once your order is handed over to the carrier, both the carrier and you are responsible for the package. To ensure your package during transit, please select the second shipping option, which includes insurance for an extra $10.<\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_181' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_2_181' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_11' class='gform_page' data-js='page-field-id-181' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_132\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full nt-step-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Complete Your Payment<\/h2>\n<\/div><div id=\"field_2_148\" class=\"gfield gfield--type-coupon gfield--input-type-coupon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gf_coupon_code_2'>Have a Promo Code?<\/label><div class='ginput_container' id='gf_coupons_container_2'><div class='ginput_container_coupon'><input id='gf_coupon_code_2' class='gf_coupon_code' onkeyup='DisableApplyButton(2);' onchange='DisableApplyButton(2);' onpaste='setTimeout(function(){DisableApplyButton(2);}, 50);' type='text'    \/><input type='button' disabled='disabled' onclick='ApplyCouponCode(2);' value='Apply' id='gf_coupon_button' class='button'  \/> <img style='display:none;' id='gf_coupon_spinner' src='https:\/\/simplefixrx.com\/wp-content\/plugins\/gravityformscoupons\/images\/spinner.gif' alt='please wait'\/><\/div><div id='gf_coupon_info'><\/div><input type='hidden' id='gf_coupon_codes_2' name='input_148' value=''  \/><input type='hidden' id='gf_total_no_discount_2'\/><input type='hidden' id='gf_coupons_2' name='gf_coupons_2' value='' \/><\/div><\/div><div id=\"field_2_249\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div id=\"addons-cart\">\n  <h3>Your Selected Add-ons<\/h3>\n  <ul id=\"selected-addons-list\"><\/ul>\n<\/div>\n\n<\/div><div id=\"field_2_257\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><script>\ndocument.addEventListener('DOMContentLoaded', function () {\n  function updateTotal() {\n    let total = 0;\n\n    \/\/ Anti-Nausea Medication - $30\n    if (document.querySelector('#choice_2_251_1')?.checked) total += 30;\n\n    \/\/ B12 - $79\n    if (document.querySelector('#choice_2_252_1')?.checked) total += 79;\n\n    \/\/ Phentermine options\n    if (document.querySelector('#choice_2_253_1')?.checked) total += 99;\n    if (document.querySelector('#choice_2_253_2')?.checked) total += 127;\n    if (document.querySelector('#choice_2_253_3')?.checked) total += 155;\n\n    \/\/ NAD - Anti-Aging\n    if (document.querySelector('#choice_2_255_1')?.checked) total += 185;\n    if (document.querySelector('#choice_2_255_2')?.checked) total += 320;\n\n    \/\/ Update Total field (#input_2_179)\n    const totalField = document.querySelector('#input_2_179');\n    if (totalField) {\n      totalField.value = '$' + total.toFixed(2);\n      totalField.dispatchEvent(new Event('input', { bubbles: true }));\n    }\n  }\n\n  \/\/ Add change event listeners to checkboxes\n  document.querySelectorAll('#gform_2 input[type=\"checkbox\"]').forEach(function (checkbox) {\n    checkbox.addEventListener('change', updateTotal);\n  });\n\n  \/\/ Initial total calculation\n  updateTotal();\n});\n<\/script>\n<\/div><div id=\"field_2_179\" class=\"gfield gfield--type-total gfield--input-type-total gfield--width-full gfield_price gfield_price_2_ gfield_total gfield_total_2_ field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  aria-atomic=\"true\" aria-live=\"polite\" ><label class='gfield_label gform-field-label' for='input_2_179'>Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_179' id='input_2_179' value='$0.00' class='gform-text-input-reset ginput_total ginput_total_2' \/>\n\t\t\t\t\t\t<\/div><\/div><fieldset id=\"field_2_142\" class=\"gfield gfield--type-creditcard gfield--input-type-creditcard gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Credit Card<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_creditcard gform-grid-row' id='input_2_142'><span class='ginput_full gform-grid-col' id='input_2_142_1_container' >\n                                    <div class='gform_card_icon_container'><div class='gform_card_icon gform_card_icon_amex' >American Express<\/div><div class='gform_card_icon gform_card_icon_discover' >Discover<\/div><div class='gform_card_icon gform_card_icon_mastercard' >MasterCard<\/div><div class='gform_card_icon gform_card_icon_visa' >Visa<\/div><span class='screen-reader-text' id='field_2_142_supported_creditcards'>Supported Credit Cards: American Express, Discover, MasterCard, Visa<\/span><\/div>\n                                    <input type='text' name='input_142.1' id='input_2_142_1' value=''   onchange='gformMatchCard(\"input_2_142_1\");' onkeyup='gformMatchCard(\"input_2_142_1\");' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='true'  \/>\n                                    <label for='input_2_142_1' id='input_2_142_1_label' class='gform-field-label gform-field-label--type-sub '>Card Number<\/label>\n                                 <\/span><span class='ginput_full ginput_cardextras gform-grid-col gform-grid-row' id='input_2_142_2_container'>\n                                            <fieldset class='ginput_cardinfo_left gform-grid-col' id='input_2_142_2_cardinfo_left'>\n                                            <legend class='gform-field-label gform-field-label--type-sub '>Expiration Date<\/legend>\n                                                <span class='ginput_card_expiration_container ginput_card_field gform-grid-row'>\n                                                   <span class='ginput_card_expiration_month_container gform-grid-col'>\n                                                       <label for='input_2_142_2_month' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                                       <select name='input_142.2[]' id='input_2_142_2_month'   class='ginput_card_expiration ginput_card_expiration_month' aria-required='true'  >\n                                                           <option value=''>Month<\/option><option value='1' >01<\/option><option value='2' >02<\/option><option value='3' >03<\/option><option value='4' >04<\/option><option value='5' >05<\/option><option value='6' >06<\/option><option value='7' >07<\/option><option value='8' >08<\/option><option value='9' >09<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option>\n                                                       <\/select>\n                                                   <\/span>\n                                                   <span class='ginput_card_expiration_year_container gform-grid-col'>\n                                                       <label for='input_2_142_2_year' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                                       <select name='input_142.2[]' id='input_2_142_2_year'   class='ginput_card_expiration ginput_card_expiration_year' aria-required='true'  >\n                                                           <option value=''>Year<\/option><option value='2026' >2026<\/option><option value='2027' >2027<\/option><option value='2028' >2028<\/option><option value='2029' >2029<\/option><option value='2030' >2030<\/option><option value='2031' >2031<\/option><option value='2032' >2032<\/option><option value='2033' >2033<\/option><option value='2034' >2034<\/option><option value='2035' >2035<\/option><option value='2036' >2036<\/option><option value='2037' >2037<\/option><option value='2038' >2038<\/option><option value='2039' >2039<\/option><option value='2040' >2040<\/option><option value='2041' >2041<\/option><option value='2042' >2042<\/option><option value='2043' >2043<\/option><option value='2044' >2044<\/option><option value='2045' >2045<\/option>\n                                                       <\/select>\n                                                   <\/span>\n                                                <\/span>\n                                            <\/fieldset><span class='ginput_cardinfo_right gform-grid-col' id='input_2_142_2_cardinfo_right'>\n                                                <input type='text' name='input_142.3' id='input_2_142_3'   class='ginput_card_security_code' value='' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='true'  \/>\n                                                <span class='ginput_card_security_code_icon'>&nbsp;<\/span>\n                                                <label for='input_2_142_3' class='gform-field-label gform-field-label--type-sub '>Security Code<\/label>\n                                             <\/span>\n                                        <\/span><span class='ginput_full gform-grid-col' id='input_2_142_5_container'>\n                                            <input type='text' name='input_142.5' id='input_2_142_5' value=''    aria-required='false'  \/>\n                                            <label for='input_2_142_5' id='input_2_142_5_label' class='gform-field-label gform-field-label--type-sub '>Cardholder Name<\/label>\n                                        <\/span> <\/div><\/fieldset><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_2' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_2' class='gform_button button gform-button--width-full' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Place Order'  \/> <input type='hidden' name='gform_ajax' value='form_id=2&amp;title=&amp;description=&amp;tabindex=0&amp;theme=orbital&amp;styles=[]&amp;hash=00e1e3bc8614cf590de2ab23d186fc10' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_2' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_2' id='gform_theme_2' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_2' id='gform_style_settings_2' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='79DZ7JGATSdduzlRReRbG97YQBiYQZZWoKuove\/\/mDF3PWZK3mXU7DiVWe8qHTpCSJKcUBiqmSVIMN8ITQoySQJAYcNbdk81mf1bYdaivojTmPA=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' value='["{\"24\":[\"ebfab7aebb0af6013d81123bf09f181a\",\"cd61acbb08c19bb3eaf61aa6df987221\",\"23d4688b5972c8da3591c90fcb094f4e\",\"09c2f46b90aa19f807bd460376b6d00c\",\"b292328de94c662548838df0a1a9dc0b\",\"626b1178394c005b161440cd4beb92cd\"],\"266\":[\"ebfab7aebb0af6013d81123bf09f181a\",\"cd61acbb08c19bb3eaf61aa6df987221\",\"23d4688b5972c8da3591c90fcb094f4e\",\"09c2f46b90aa19f807bd460376b6d00c\",\"b292328de94c662548838df0a1a9dc0b\"],\"265\":[\"d1f225b8d284c51009806c5d730bb6c2\",\"7f9c354c3d3c5aaee56e5c886518bfa5\"],\"30\":[\"04b960eefa3647ddfa88ff6214b6fcc3\",\"5708c852bef30d015055228baa128006\",\"c61032acd6553f96eaae2b7d218851bb\",\"30353b24c3da29689a4b6d1878c4d474\",\"d3abc2e0ebb82273b116debf61a188ba\",\"fb4929e0cb9d9928c198c9955ba3fa5c\"],\"31\":[\"89671abf6f821792b79174d1411289b2\",\"ed48270445d32f85062e96e7d8deb3ca\",\"c4ccecfe9e6dfac9652d98249c046036\",\"e2992ce8e39cb6947308b8cc1595eb97\",\"fb4929e0cb9d9928c198c9955ba3fa5c\"],\"178.1\":\"777b1d8d4d1955005369e699dc5885f1\",\"178.2\":\"24cd974bc06c7a780997c08f3ac4a1ab\",\"178.3\":\"62eb5560f5684a7b023b5cda4dddfc4e\",\"178.4\":\"2c084a064256fff29dc957ab225c8145\",\"178.5\":\"afeb2cb35c1dde67d2bb34daa93d3c84\",\"178.6\":\"cd3b358ea3fdc98a931dcca1eac025ff\",\"178.7\":\"f302ca7ce510ab6292c12ec3cf9b242b\",\"178.8\":\"bc3aa478879d7b5f49f7bccfc63dc08c\",\"34\":[\"3e44a0263f37b57ff522b21d472723fe\",\"a06095058004a4adf07762e16b49965a\",\"8543bf265852f4a727d106d18b18dcd7\",\"13fb6c6cfb1421a5902e2db5818a9394\",\"1bfa9b89e5724aaebe8ef108344eea1a\"],\"35\":[\"34897f0b6e4f67b412996d37474778a2\",\"219d14fbd5c4cdec894f45d8b038ef36\"],\"36\":[\"34897f0b6e4f67b412996d37474778a2\",\"219d14fbd5c4cdec894f45d8b038ef36\"],\"37\":[\"d0c2773102475fb016457e26187a10a9\",\"a3b525c193044b69cfc7f59b776d7af8\"],\"38\":[\"bf720e4efe865a1ca81e6a6d661a2dc3\",\"ad0182e0c20fae08aa267650160d0ee6\",\"bb9c6d6113af9ff1c1513d00077512a6\",\"338711fe3d0c2acec4f383684ed49493\",\"09c2e9e03252abe00e33e50cdf8a6cd7\"],\"39\":[\"b1c1d866b3fac79e77c1a10441e8dc9f\",\"b2571921724f01ae34ebcf0f0f4d819b\",\"c833e7a51da89206c6861b49712d2858\"],\"40\":[\"34897f0b6e4f67b412996d37474778a2\",\"219d14fbd5c4cdec894f45d8b038ef36\"],\"41\":[\"34897f0b6e4f67b412996d37474778a2\",\"219d14fbd5c4cdec894f45d8b038ef36\"],\"182\":[\"34897f0b6e4f67b412996d37474778a2\",\"219d14fbd5c4cdec894f45d8b038ef36\"],\"43\":[\"34897f0b6e4f67b412996d37474778a2\",\"219d14fbd5c4cdec894f45d8b038ef36\"],\"44\":[\"34897f0b6e4f67b412996d37474778a2\",\"219d14fbd5c4cdec894f45d8b038ef36\"],\"45\":[\"34897f0b6e4f67b412996d37474778a2\",\"219d14fbd5c4cdec894f45d8b038ef36\"],\"46\":[\"34897f0b6e4f67b412996d37474778a2\",\"219d14fbd5c4cdec894f45d8b038ef36\"],\"155\":[\"3d4b3a51e4e362f465e49349a41bf6ea\",\"f54e46153401af104e2fa170501ba97b\"],\"264\":[\"1a0f95480861d92c3c23c8d02c732cf5\",\"6d158c13b8d30fd815d2d24f4513c705\",\"df4d05376644666c4403bb2d12c181b2\"],\"167.1\":\"91f76c6bbb9c50372eb22dfd8af9a8b6\",\"167.2\":\"eee25403f6da9226c2f89bdc92eb83be\",\"167.3\":\"cb5467f4b688dc124c0131e9a22d61b1\",\"167.4\":\"85c4656283cfa5d3bcfbd691689008d2\",\"167.5\":\"1227efba8dcae7e70b0a6e431e653993\",\"167.6\":\"252bfed723a3494c9a7fa4df645f82f0\",\"167.7\":\"c1ffdc13add32fd2e062f613639dca90\",\"11\":[\"219d14fbd5c4cdec894f45d8b038ef36\",\"34897f0b6e4f67b412996d37474778a2\"],\"20\":[\"2885a6120712a7a3db68a23304fa2873\",\"4e6e32f16343d4a5ed1431b674056dfe\",\"33142ff2f5764de1d0dc79f43e3c165b\",\"74f14fda143d155f45055e43a765b1ff\",\"434fd135972d352f912f2702942d8668\",\"9f4f16d28352a440f08d9d71b402f9cb\",\"dbefbbf885b1dac2690f9cdf59c3d0c2\",\"d24161afc1d70855d3594ebed8b83782\",\"3fcd6e53b7235650e934cec20f985454\",\"f6c013ea4fe499b8b3b741b40cf8f161\"],\"13\":[\"294913e6e1406dc7fedee61016094dd6\",\"0efb6635b2095785e5c0dd5ff02e5819\",\"b5e6f8c8b87db8de51fdd5642e8d52c1\",\"4219a95f241f3eb303d4bbf9d001cb19\",\"8650e5ef01f6297063c9d04f816f9a4d\",\"79bab22f9adda09d519c06a7c1c46b3a\",\"5f154663f1ea21d5502e74063b6ceba4\",\"97bdc6c5dd5c3b094f1ae96732c2b5b0\",\"8cf8d6d02d37f88aac393b70a2696d96\"],\"22\":[\"65131f3a256155990f199b818a746103\",\"206f553b5193f0107b190569618045dd\"],\"233\":[\"34897f0b6e4f67b412996d37474778a2\",\"219d14fbd5c4cdec894f45d8b038ef36\"],\"243\":[\"34897f0b6e4f67b412996d37474778a2\",\"219d14fbd5c4cdec894f45d8b038ef36\"],\"236\":[\"34897f0b6e4f67b412996d37474778a2\",\"219d14fbd5c4cdec894f45d8b038ef36\"],\"235\":[\"34897f0b6e4f67b412996d37474778a2\",\"219d14fbd5c4cdec894f45d8b038ef36\"],\"244\":[\"34897f0b6e4f67b412996d37474778a2\",\"219d14fbd5c4cdec894f45d8b038ef36\"],\"190\":[\"31f09156f767d607e71a6e06164bb5be\",\"626b1178394c005b161440cd4beb92cd\"],\"211\":[\"591f668468ba664e8294e9cafdd8ab39\",\"626b1178394c005b161440cd4beb92cd\"],\"188\":[\"16156d50e92acd78f017a8a51f0b353e\",\"626b1178394c005b161440cd4beb92cd\"],\"189\":[\"d69e0d3489125c7897f8aa885ba0f2f7\",\"626b1178394c005b161440cd4beb92cd\"],\"213\":[\"e19ade05dc940bd20d2c09a93eb3da28\",\"626b1178394c005b161440cd4beb92cd\"],\"230\":[\"a3cb9915508e31ca572194f1c727f9c3\",\"626b1178394c005b161440cd4beb92cd\"],\"212\":[\"e31ba3dd457de1a8746e25bd7590b9c7\",\"363574307648767184790ae313fd0e86\",\"557dbd25a813d5ee078e81d1afa0573a\",\"76fdddbdeed6f6a3d5689f1316e7a033\",\"01e19be958e4f37171fba4f45af22dfa\",\"5aedbc0dd4575c6f76fec3f592198a37\",\"ffa52d1dd705662c39734d49e6656141\",\"78ecddddf707e91d6bdad65381994926\",\"79157eb8da693659177e7824b80efb99\",\"1e0943dc8a21452ea56c07dad1134921\",\"00e1aeb9c9a2d934d9401e0532a83bbd\",\"df969fe4814400b9944d6b07e5d59d87\",\"5efa3f35bdaf776d0f5f9422c098e435\",\"d774b5f3065ee1dbc5415bd733be01ee\",\"54a6621d77931267400c3e8dbe601193\"],\"204\":[\"7cd7780490101793ce8a35e027d659f0\",\"ab9c1119508df1b360c137eae3d0aff9\",\"06f027c3a68d09775b90b8a6c83e5675\",\"aeb846ceca2fadc362154d871834f6d6\",\"842f31cf71d5551c47f9a31459c35b29\",\"ac0554e191e86cef2f2058324f8068f0\",\"de27fed2b3e9cd110dac4adb1c6d2758\",\"5ec812c9165192697b435748ad1442d8\",\"253a98b253b2769ed2073fc81914ce7f\",\"6a2207002edb13a00d12404093a56d72\",\"e228c9a9b0b2d0dfe0b5e080ba97727b\"],\"215\":[\"3d8ab7b7579de998854baa193fee2073\",\"528e11070ed241d0f75f3d9dcea1d300\",\"a7b0be04d6c964ca4dd1aad463050df5\",\"6ac8e84c90a6d06dcadebdd2f3ba5ab2\",\"bfa0b50f402de46b84aedede03011da6\",\"8ce14547a80837f5a76dbbd940d6a2f4\",\"5573103d630fe44616ab149dbbbd0e60\",\"212c3ade00cb1531bd1b7756ddd97951\"],\"267\":[\"3d8ab7b7579de998854baa193fee2073\",\"528e11070ed241d0f75f3d9dcea1d300\",\"a7b0be04d6c964ca4dd1aad463050df5\",\"6ac8e84c90a6d06dcadebdd2f3ba5ab2\",\"1ec297db24751ff8732e17d9533a7127\",\"519b98ddd9490548a769beb7812ec8c3\",\"e812674126bebed8f6e51821e3e036db\",\"bfa0b50f402de46b84aedede03011da6\",\"8ce14547a80837f5a76dbbd940d6a2f4\",\"5573103d630fe44616ab149dbbbd0e60\",\"212c3ade00cb1531bd1b7756ddd97951\",\"4dd10a8b1aa0dfb53fe8ba5f2cdb9e59\",\"2293c58a06d5bd8b5fb089d84abfd75c\",\"3583b2d7fe59a01748944e8f753d9c23\"],\"229\":[\"3d8ab7b7579de998854baa193fee2073\",\"528e11070ed241d0f75f3d9dcea1d300\",\"a7b0be04d6c964ca4dd1aad463050df5\",\"6ac8e84c90a6d06dcadebdd2f3ba5ab2\",\"bfa0b50f402de46b84aedede03011da6\",\"8ce14547a80837f5a76dbbd940d6a2f4\",\"bd0846c87ae5fadbf5583410e434068f\",\"75b16750b916208b3f0493e1a814925a\"],\"268\":[\"adf64a7eb4a0027f63f5d4305d1dea66\",\"07f90f3b3f1427d96bf1b51861efb8a1\",\"9a483931f32b109411b3263d7d808ad2\",\"1f429d271d81583a58abb398cbf89d2f\",\"bf05bb339074cec83e55ce87d71fe216\",\"918872d8e5875f7547485000b20268b8\",\"da0c63a1b3ba61476157106b75e1676d\",\"bfa0b50f402de46b84aedede03011da6\",\"8ce14547a80837f5a76dbbd940d6a2f4\",\"bd0846c87ae5fadbf5583410e434068f\",\"75b16750b916208b3f0493e1a814925a\",\"bcdb526a636ccbfde3a4d5f14dab645b\",\"82ab2d5ff0cd1125686ed2fa2ffc5a6c\",\"871d8e379daf9150adeab4c4f5bd5896\"],\"177\":[\"1a4aade1727a87c2187d1ff58673a37c\",\"579ec3961501a07beea7fbc42639ac83\",\"96fe01e6900e5c7be32293ed02c741dd\",\"1fe08ace7cd8b8ee55d497608dbc0d3e\",\"d5e4cf0f020d5494ff521cb3cc3cfff0\",\"16d9030d646b95cba093628909af4839\",\"1dab0a1be39c8c65d1eb56b091833245\",\"a8b090855b06d51ac4521db280ada738\",\"695340ec5d5de4c8d084154f4cf9d5ae\",\"cf9aad1b6d0173d84c3f894f4bf5c21d\",\"af87858aae598fac9de4584078531d14\",\"a7cd84364c314ca3e04b2177a289f141\",\"a8b090855b06d51ac4521db280ada738\"],\"251.1\":\"26e9cceada8cdfc6c5794e3ce47083b9\",\"260\":[\"6d7f8fbd04ac1b31cb9eaa4a499b63a6\"],\"261\":[\"a818684fdd7b2311da81fbef21f5724b\"],\"263\":[\"83d36d37c8aebfcc9a733b065b8a383a\",\"3687965fe3a23ce8ef4762b75a650e86\",\"0610399dd79a1c58702c5ef9bc867d72\"],\"262\":[\"4841a151608ea7228d9565f937ab5714\",\"982087a08b5877033af3c9effb69f567\"],\"252.1\":\"fe59197aa525888ce1572059a3bac9d3\",\"253.1\":\"d3b7bc84358ca48ec69949a751015bab\",\"253.2\":\"e993665e6023f0a0d35877041a737c41\",\"253.3\":\"b3be3f7e28fde293919ef0dcba7253ff\",\"255.1\":\"d73e51cf8423eb079b95f8f6d4c43c16\",\"255.2\":\"4775ab0a9e7769c14fb5d0d1cce25088\",\"218\":[\"89e61afbc1ddeeddc7a3c468e8332dbb\",\"e7ca64f4fb4b756c85f3b71bf3d429d4\",\"74779774d073305d90635e8a259ccf9a\"],\"219.1\":\"3481d248b944495af4677b1db50fe33e\",\"219.2\":\"8ee9ab3d1ee3e3ec75373426319a3178\",\"220\":[\"89e61afbc1ddeeddc7a3c468e8332dbb\",\"e7ca64f4fb4b756c85f3b71bf3d429d4\",\"74779774d073305d90635e8a259ccf9a\"],\"221.1\":\"965b4c7228112344bdc32718a40ecee0\",\"221.2\":\"bf45bead632cf233d1322ce29d0c46fe\",\"231\":[\"c558d3fd229b2b6e0d35bae6e6695bac\",\"fe44a33fb9445a7141ce454e78731396\",\"4c5de7039fd81a6e06f4db5c30760bd1\"],\"206\":[\"89e61afbc1ddeeddc7a3c468e8332dbb\",\"e7ca64f4fb4b756c85f3b71bf3d429d4\",\"74779774d073305d90635e8a259ccf9a\"],\"207.1\":\"410bf2604212c3d95eb3cdb1e8cbc76b\",\"207.2\":\"8ee9ab3d1ee3e3ec75373426319a3178\",\"209\":[\"89e61afbc1ddeeddc7a3c468e8332dbb\",\"e7ca64f4fb4b756c85f3b71bf3d429d4\",\"74779774d073305d90635e8a259ccf9a\"],\"210.1\":\"d7d51fef7c9e1fa322536c34f378fb99\",\"210.2\":\"a7e368a19edb55f982d4bce639af5dbf\",\"226\":[\"89e61afbc1ddeeddc7a3c468e8332dbb\",\"e7ca64f4fb4b756c85f3b71bf3d429d4\",\"74779774d073305d90635e8a259ccf9a\"],\"227.1\":\"7bcd6b5f719941ddf0f7a3fdca4a9e19\",\"227.2\":\"42a985decce8d7dd3d7f1f56adbf2ae5\",\"193\":[\"89e61afbc1ddeeddc7a3c468e8332dbb\",\"e7ca64f4fb4b756c85f3b71bf3d429d4\",\"74779774d073305d90635e8a259ccf9a\"],\"195.1\":\"f2ec6e52dfd39e55ac5751bc7361a97e\",\"195.2\":\"1cde71614d7a20394d2c5815e0bbb01f\",\"196\":[\"89e61afbc1ddeeddc7a3c468e8332dbb\",\"e7ca64f4fb4b756c85f3b71bf3d429d4\",\"74779774d073305d90635e8a259ccf9a\"],\"197.1\":\"673d37338d7a5ac9048bb9db4db91e95\",\"197.2\":\"29d51d6644e1643088d00d95f218015e\",\"201\":[\"89e61afbc1ddeeddc7a3c468e8332dbb\",\"e7ca64f4fb4b756c85f3b71bf3d429d4\",\"74779774d073305d90635e8a259ccf9a\"],\"202.1\":\"277a15417121692ef310be6934eae496\",\"202.2\":\"29d51d6644e1643088d00d95f218015e\",\"203\":[\"84d283b9c356d87254d921f846e687ed\",\"0e706ef8d69b2ce20bad6e1a1c4d9143\",\"8b34ad1a082db9268b737eba2aaed7dd\"],\"222\":[\"89e61afbc1ddeeddc7a3c468e8332dbb\",\"e7ca64f4fb4b756c85f3b71bf3d429d4\",\"74779774d073305d90635e8a259ccf9a\"],\"223.1\":\"843f26480b34523b40b2c8ebd6e9010e\",\"223.2\":\"29d51d6644e1643088d00d95f218015e\",\"224\":[\"84d283b9c356d87254d921f846e687ed\",\"0e706ef8d69b2ce20bad6e1a1c4d9143\",\"8b34ad1a082db9268b737eba2aaed7dd\"],\"154\":[\"e19a888e96e60dd86fc11403835ae71a\",\"84af821a59713f4912fdc207dc94494a\"]}","77e8bbf9218a35921ba5dcd2622ae7ac"]' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_2' id='gform_target_page_number_2' value='2' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_2' id='gform_source_page_number_2' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n             <\/div><\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_2' id='gform_ajax_frame_2' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 2, 'https:\/\/simplefixrx.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', false );jQuery('#gform_ajax_frame_2').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_2');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_2').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_2').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_2').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_2').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_2').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_2').val();gformInitSpinner( 2, 'https:\/\/simplefixrx.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', false );jQuery(document).trigger('gform_page_loaded', [2, current_page]);window['gf_submitting_2'] = 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_2').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_2').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [2]);window['gf_submitting_2'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_2').text());}else{jQuery('#gform_2').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"2\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_2\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_2\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_2\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 2, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, 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>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":23,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"googlesitekit_rrm_CAowkq3dCw:productID":"","footnotes":""},"class_list":["post-1208","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>GLP-1 (Glucagon-Like Peptide-1)<\/title>\n<meta name=\"description\" content=\"Discover the benefits of GLP-1, a powerful hormone that regulates appetite, improves insulin response, and supports weight loss.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/simplefixrx.com\/es\/order\/\" \/>\n<meta property=\"og:locale\" content=\"es_MX\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"GLP-1 (Glucagon-Like Peptide-1)\" \/>\n<meta property=\"og:description\" content=\"Discover the benefits of GLP-1, a powerful hormone that regulates appetite, improves insulin response, and supports weight loss.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/simplefixrx.com\/es\/order\/\" \/>\n<meta property=\"og:site_name\" content=\"SimpleFix Rx\" \/>\n<meta property=\"article:modified_time\" content=\"2025-07-25T18:07:10+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Tiempo de lectura\" \/>\n\t<meta name=\"twitter:data1\" content=\"1 minuto\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/simplefixrx.com\/order\/\",\"url\":\"https:\/\/simplefixrx.com\/order\/\",\"name\":\"GLP-1 (Glucagon-Like Peptide-1)\",\"isPartOf\":{\"@id\":\"https:\/\/simplefixrx.com\/#website\"},\"datePublished\":\"2025-05-24T09:54:43+00:00\",\"dateModified\":\"2025-07-25T18:07:10+00:00\",\"description\":\"Discover the benefits of GLP-1, a powerful hormone that regulates appetite, improves insulin response, and supports weight loss.\",\"breadcrumb\":{\"@id\":\"https:\/\/simplefixrx.com\/order\/#breadcrumb\"},\"inLanguage\":\"es\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/simplefixrx.com\/order\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/simplefixrx.com\/order\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/simplefixrx.com\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"1 &#8211; GLP-1 Questionnaire Form\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\/\/simplefixrx.com\/#website\",\"url\":\"https:\/\/simplefixrx.com\/\",\"name\":\"SimpleFix Rx\",\"description\":\"\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/simplefixrx.com\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"es\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"GLP-1 (Glucagon-Like Peptide-1)","description":"Discover the benefits of GLP-1, a powerful hormone that regulates appetite, improves insulin response, and supports weight loss.","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/simplefixrx.com\/es\/order\/","og_locale":"es_MX","og_type":"article","og_title":"GLP-1 (Glucagon-Like Peptide-1)","og_description":"Discover the benefits of GLP-1, a powerful hormone that regulates appetite, improves insulin response, and supports weight loss.","og_url":"https:\/\/simplefixrx.com\/es\/order\/","og_site_name":"SimpleFix Rx","article_modified_time":"2025-07-25T18:07:10+00:00","twitter_card":"summary_large_image","twitter_misc":{"Tiempo de lectura":"1 minuto"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/simplefixrx.com\/order\/","url":"https:\/\/simplefixrx.com\/order\/","name":"GLP-1 (Glucagon-Like Peptide-1)","isPartOf":{"@id":"https:\/\/simplefixrx.com\/#website"},"datePublished":"2025-05-24T09:54:43+00:00","dateModified":"2025-07-25T18:07:10+00:00","description":"Discover the benefits of GLP-1, a powerful hormone that regulates appetite, improves insulin response, and supports weight loss.","breadcrumb":{"@id":"https:\/\/simplefixrx.com\/order\/#breadcrumb"},"inLanguage":"es","potentialAction":[{"@type":"ReadAction","target":["https:\/\/simplefixrx.com\/order\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/simplefixrx.com\/order\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/simplefixrx.com\/"},{"@type":"ListItem","position":2,"name":"1 &#8211; GLP-1 Questionnaire Form"}]},{"@type":"WebSite","@id":"https:\/\/simplefixrx.com\/#website","url":"https:\/\/simplefixrx.com\/","name":"SimpleFix Rx","description":"","potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/simplefixrx.com\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"es"}]}},"_links":{"self":[{"href":"https:\/\/simplefixrx.com\/es\/wp-json\/wp\/v2\/pages\/1208","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/simplefixrx.com\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/simplefixrx.com\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/simplefixrx.com\/es\/wp-json\/wp\/v2\/users\/23"}],"replies":[{"embeddable":true,"href":"https:\/\/simplefixrx.com\/es\/wp-json\/wp\/v2\/comments?post=1208"}],"version-history":[{"count":0,"href":"https:\/\/simplefixrx.com\/es\/wp-json\/wp\/v2\/pages\/1208\/revisions"}],"wp:attachment":[{"href":"https:\/\/simplefixrx.com\/es\/wp-json\/wp\/v2\/media?parent=1208"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}