{"id":1230,"date":"2025-05-27T09:12:20","date_gmt":"2025-05-27T14:12:20","guid":{"rendered":"https:\/\/simplefixrx.com\/?page_id=1230"},"modified":"2025-07-25T13:05:42","modified_gmt":"2025-07-25T18:05:42","slug":"1-nad-questionnaire","status":"publish","type":"page","link":"https:\/\/simplefixrx.com\/es\/1-nad-questionnaire\/","title":{"rendered":"1 &#8211; NAD+ Questionnaire"},"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 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step='1'\/>\n                                            <label for='input_33_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_33_5_3_container'>\n                                            <input type='number' maxlength='4' name='input_5[]' id='input_33_5_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_33_5_3' class='gform-field-label gform-field-label--type-sub '>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_33_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_33_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_33_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_33_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_33_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_33_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_33_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_33_228'>Google Ad Source<\/label><div class='ginput_container ginput_container_text'><input name='input_228' id='input_33_228' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_33_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_visible\"  ><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_33_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_33_2' class='gform_page' data-js='page-field-id-169' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_33_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_33_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_33_250\" 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 physically active are 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_33_250'>\n\t\t\t<div class='gchoice gchoice_33_250_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_250' type='radio' value='Sedentary'  id='choice_33_250_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_250_0' id='label_33_250_0' class='gform-field-label gform-field-label--type-inline'>Sedentary<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_250_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_250' type='radio' value='Active but not athletic'  id='choice_33_250_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_250_1' id='label_33_250_1' class='gform-field-label gform-field-label--type-inline'>Active but not athletic<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_250_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_250' type='radio' value='Somewhat Active'  id='choice_33_250_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_250_2' id='label_33_250_2' class='gform-field-label gform-field-label--type-inline'>Somewhat Active<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_250_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_250' type='radio' value='Athletic'  id='choice_33_250_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_250_3' id='label_33_250_3' class='gform-field-label gform-field-label--type-inline'>Athletic<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_250_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_250' type='radio' value='Competitive\/Biohacker'  id='choice_33_250_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_250_4' id='label_33_250_4' class='gform-field-label gform-field-label--type-inline'>Competitive\/Biohacker<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_33_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' >Which of the following apply to your reproductive status?<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_33_24'>\n\t\t\t<div class='gchoice gchoice_33_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='I am not currently pregnant or breastfeeding'  id='choice_33_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_24_0' id='label_33_24_0' class='gform-field-label gform-field-label--type-inline'>I am not currently pregnant or breastfeeding<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='I am currently pregnant or breastfeeding'  id='choice_33_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_24_1' id='label_33_24_1' class='gform-field-label gform-field-label--type-inline'>I am currently pregnant or breastfeeding<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_24_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='I plan to become pregnant or breastfeed within next 6months'  id='choice_33_24_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_24_2' id='label_33_24_2' class='gform-field-label gform-field-label--type-inline'>I plan to become pregnant or breastfeed within next 6months<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_24_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='I am currently going through menopause'  id='choice_33_24_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_24_3' id='label_33_24_3' class='gform-field-label gform-field-label--type-inline'>I am currently going through menopause<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_24_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='I had a hysterectomy or am post-menopause'  id='choice_33_24_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_24_4' id='label_33_24_4' class='gform-field-label gform-field-label--type-inline'>I had a hysterectomy or am post-menopause<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_33_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' >Do you have any one of the following Medical 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_33_46'>\n\t\t\t<div class='gchoice gchoice_33_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Diabetes'  id='choice_33_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_46_0' id='label_33_46_0' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Hypertension(High Blood Pressure)'  id='choice_33_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_46_1' id='label_33_46_1' class='gform-field-label gform-field-label--type-inline'>Hypertension(High Blood Pressure)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_46_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Thyroid condition'  id='choice_33_46_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_46_2' id='label_33_46_2' class='gform-field-label gform-field-label--type-inline'>Thyroid condition<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_46_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Asthma or COPD'  id='choice_33_46_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_46_3' id='label_33_46_3' class='gform-field-label gform-field-label--type-inline'>Asthma or COPD<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_46_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Anxiety or depression'  id='choice_33_46_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_46_4' id='label_33_46_4' class='gform-field-label gform-field-label--type-inline'>Anxiety or depression<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_46_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='HIV OR AIDS'  id='choice_33_46_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_46_5' id='label_33_46_5' class='gform-field-label gform-field-label--type-inline'>HIV OR AIDS<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_46_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Kidney disease'  id='choice_33_46_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_46_6' id='label_33_46_6' class='gform-field-label gform-field-label--type-inline'>Kidney disease<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_46_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Cancer'  id='choice_33_46_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_46_7' id='label_33_46_7' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_46_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Arrhythmia or irregular heart beat'  id='choice_33_46_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_46_8' id='label_33_46_8' class='gform-field-label gform-field-label--type-inline'>Arrhythmia or irregular heart beat<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_46_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Vascular disease(stroke, blood clots etc)'  id='choice_33_46_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_46_9' id='label_33_46_9' class='gform-field-label gform-field-label--type-inline'>Vascular disease(stroke, blood clots etc)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_46_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='HeartFailure'  id='choice_33_46_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_46_10' id='label_33_46_10' class='gform-field-label gform-field-label--type-inline'>HeartFailure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_46_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Gallbladder disease'  id='choice_33_46_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_46_11' id='label_33_46_11' class='gform-field-label gform-field-label--type-inline'>Gallbladder disease<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_46_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Liver disease'  id='choice_33_46_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_46_12' id='label_33_46_12' class='gform-field-label gform-field-label--type-inline'>Liver disease<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_46_13'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='None of the above'  id='choice_33_46_13' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_46_13' id='label_33_46_13' 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_33_261\" 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 told your liver is not working properly?<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_33_261'>\n\t\t\t<div class='gchoice gchoice_33_261_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_261' type='radio' value='Yes'  id='choice_33_261_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_261_0' id='label_33_261_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_33_261_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_261' type='radio' value='No'  id='choice_33_261_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_261_1' id='label_33_261_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_33_262\" 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_33_262'>If Yes, Please explain.<\/label><div class='ginput_container ginput_container_text'><input name='input_262' id='input_33_262' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_33_257\" 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 told your heart is not pumping properly?<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_33_257'>\n\t\t\t<div class='gchoice gchoice_33_257_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_257' type='radio' value='Yes'  id='choice_33_257_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_257_0' id='label_33_257_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_33_257_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_257' type='radio' value='No'  id='choice_33_257_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_257_1' id='label_33_257_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_33_263\" 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_33_263'>If Yes, Please explain.<\/label><div class='ginput_container ginput_container_text'><input name='input_263' id='input_33_263' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_33_255\" 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 currently smoke?<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_33_255'>\n\t\t\t<div class='gchoice gchoice_33_255_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_255' type='radio' value='Yes'  id='choice_33_255_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_255_0' id='label_33_255_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_33_255_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_255' type='radio' value='No'  id='choice_33_255_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_255_1' id='label_33_255_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_33_265\" 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_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do any of your immediate family members have a history of the following conditions?(Check all that apply)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_33_265'><div class='gchoice gchoice_33_265_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_265.1' type='checkbox'  value='High Cholesterol'  id='choice_33_265_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_33_265_1' id='label_33_265_1' class='gform-field-label gform-field-label--type-inline'>High Cholesterol<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_33_265_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_265.2' type='checkbox'  value='Fatty Liver Disease'  id='choice_33_265_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_33_265_2' id='label_33_265_2' class='gform-field-label gform-field-label--type-inline'>Fatty Liver Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_33_265_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_265.3' type='checkbox'  value='High Blood Pressure'  id='choice_33_265_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_33_265_3' id='label_33_265_3' class='gform-field-label gform-field-label--type-inline'>High Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_33_265_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_265.4' type='checkbox'  value='Pre Diabetes\/ Type 2 Diabetes\/ Hbac 1 above 5.7'  id='choice_33_265_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_33_265_4' id='label_33_265_4' class='gform-field-label gform-field-label--type-inline'>Pre Diabetes\/ Type 2 Diabetes\/ Hbac 1 above 5.7<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_33_265_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_265.5' type='checkbox'  value='Cancer'  id='choice_33_265_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_33_265_5' id='label_33_265_5' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_33_265_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_265.6' type='checkbox'  value='Heart disease'  id='choice_33_265_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_33_265_6' id='label_33_265_6' class='gform-field-label gform-field-label--type-inline'>Heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_33_265_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_265.7' type='checkbox'  value='Dementia'  id='choice_33_265_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_33_265_7' id='label_33_265_7' class='gform-field-label gform-field-label--type-inline'>Dementia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_33_265_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_265.8' type='checkbox'  value='None of the above'  id='choice_33_265_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_33_265_8' id='label_33_265_8' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_33_265_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_265.9' type='checkbox'  value='Other'  id='choice_33_265_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_33_265_9' id='label_33_265_9' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_33_258\" 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 a primary care provider?<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_33_258'>\n\t\t\t<div class='gchoice gchoice_33_258_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='Yes'  id='choice_33_258_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_258_0' id='label_33_258_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_33_258_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='No'  id='choice_33_258_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_258_1' id='label_33_258_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_33_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' >Have you had a general health check-up or routine physical in the past three years?<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_33_266'>\n\t\t\t<div class='gchoice gchoice_33_266_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_266' type='radio' value='Yes'  id='choice_33_266_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_266_0' id='label_33_266_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_33_266_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_266' type='radio' value='No'  id='choice_33_266_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_266_1' id='label_33_266_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_33_267\" 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 any allergies?<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_33_267'>\n\t\t\t<div class='gchoice gchoice_33_267_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='Yes'  id='choice_33_267_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_267_0' id='label_33_267_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_33_267_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='No'  id='choice_33_267_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_267_1' id='label_33_267_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_33_32\" 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_33_32'>If Yes, Please list all.<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_33_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_33_251\" 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 any medical conditions our physicians should know about?<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_33_251'>\n\t\t\t<div class='gchoice gchoice_33_251_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_251' type='radio' value='Yes'  id='choice_33_251_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_251_0' id='label_33_251_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_33_251_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_251' type='radio' value='No'  id='choice_33_251_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_251_1' id='label_33_251_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_33_259\" 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_33_259'>If Yes, Please list.<\/label><div class='ginput_container ginput_container_text'><input name='input_259' id='input_33_259' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_33_269\" 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_33_269'>Why are you interested in NAD Injections?<\/label><div class='ginput_container ginput_container_text'><input name='input_269' id='input_33_269' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_33_268\" 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 used NAD+ by patch, IV infusion, injection or nasal spray?<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_33_268'>\n\t\t\t<div class='gchoice gchoice_33_268_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_268' type='radio' value='Yes'  id='choice_33_268_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_268_0' id='label_33_268_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_33_268_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_268' type='radio' value='No'  id='choice_33_268_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_268_1' id='label_33_268_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_33_271\" 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_33_271'>Please describe and include any reactions, side effects and\/or benefits you may have experienced<\/label><div class='ginput_container ginput_container_text'><input name='input_271' id='input_33_271' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_33_270\" 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 feel comfortable drawing up the NAD+ solution and injecting yourself using an insulin-sized needle and syringe?<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_33_270'>\n\t\t\t<div class='gchoice gchoice_33_270_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_270' type='radio' value='Yes'  id='choice_33_270_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_270_0' id='label_33_270_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_33_270_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_270' type='radio' value='No'  id='choice_33_270_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_270_1' id='label_33_270_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_33_278\" 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 been diagnosed with vitamin B12 deficiency by a physician or other healthcare professional?<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_33_278'>\n\t\t\t<div class='gchoice gchoice_33_278_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_278' type='radio' value='Yes'  id='choice_33_278_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_278_0' id='label_33_278_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_33_278_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_278' type='radio' value='No'  id='choice_33_278_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_278_1' id='label_33_278_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_33_279\" 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 been diagnosed with vitamin B12 deficiency by a physician or other healthcare professional?<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_33_279'>\n\t\t\t<div class='gchoice gchoice_33_279_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_279' type='radio' value='Leber&#039;s optic neuropathy'  id='choice_33_279_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_279_0' id='label_33_279_0' class='gform-field-label gform-field-label--type-inline'>Leber's optic neuropathy<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_279_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_279' type='radio' value='Polycythemia Vera'  id='choice_33_279_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_279_1' id='label_33_279_1' class='gform-field-label gform-field-label--type-inline'>Polycythemia Vera<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_279_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_279' type='radio' value='Gout'  id='choice_33_279_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_279_2' id='label_33_279_2' class='gform-field-label gform-field-label--type-inline'>Gout<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_279_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_279' type='radio' value='Low potassium levels'  id='choice_33_279_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_279_3' id='label_33_279_3' class='gform-field-label gform-field-label--type-inline'>Low potassium levels<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_279_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_279' type='radio' value='Anemia for any reason other than low vitamin B12'  id='choice_33_279_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_279_4' id='label_33_279_4' class='gform-field-label gform-field-label--type-inline'>Anemia for any reason other than low vitamin B12<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_279_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_279' type='radio' value='Any other blood disorder'  id='choice_33_279_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_279_5' id='label_33_279_5' class='gform-field-label gform-field-label--type-inline'>Any other blood disorder<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_279_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_279' type='radio' value='None of the above'  id='choice_33_279_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_279_6' id='label_33_279_6' 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_33_280\" 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 been diagnosed with vitamin B12 deficiency by a physician or other healthcare professional?<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_33_280'>\n\t\t\t<div class='gchoice gchoice_33_280_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_280' type='radio' value='Leber&#039;s optic neuropathy'  id='choice_33_280_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_280_0' id='label_33_280_0' class='gform-field-label gform-field-label--type-inline'>Leber's optic neuropathy<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_280_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_280' type='radio' value='Polycythemia Vera'  id='choice_33_280_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_280_1' id='label_33_280_1' class='gform-field-label gform-field-label--type-inline'>Polycythemia Vera<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_280_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_280' type='radio' value='Gout'  id='choice_33_280_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_280_2' id='label_33_280_2' class='gform-field-label gform-field-label--type-inline'>Gout<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_280_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_280' type='radio' value='Low potassium levels'  id='choice_33_280_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_280_3' id='label_33_280_3' class='gform-field-label gform-field-label--type-inline'>Low potassium levels<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_280_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_280' type='radio' value='Anemia for any reason other than low vitamin B12'  id='choice_33_280_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_280_4' id='label_33_280_4' class='gform-field-label gform-field-label--type-inline'>Anemia for any reason other than low vitamin B12<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_280_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_280' type='radio' value='Any other blood disorder'  id='choice_33_280_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_280_5' id='label_33_280_5' class='gform-field-label gform-field-label--type-inline'>Any other blood disorder<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_280_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_280' type='radio' value='None of the above'  id='choice_33_280_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_280_6' id='label_33_280_6' 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_33_283\" 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 pregnant, planning to become pregnant, or 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_33_283'>\n\t\t\t<div class='gchoice gchoice_33_283_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_283' type='radio' value='Currently pregnant'  id='choice_33_283_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_283_0' id='label_33_283_0' class='gform-field-label gform-field-label--type-inline'>Currently pregnant<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_283_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_283' type='radio' value='Planning to become pregnant within the next 6 months'  id='choice_33_283_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_283_1' id='label_33_283_1' class='gform-field-label gform-field-label--type-inline'>Planning to become pregnant within the next 6 months<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_283_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_283' type='radio' value='Breastfeeding'  id='choice_33_283_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_283_2' id='label_33_283_2' class='gform-field-label gform-field-label--type-inline'>Breastfeeding<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_283_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_283' type='radio' value='None of the above'  id='choice_33_283_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_283_3' id='label_33_283_3' 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_33_282\" 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 benefits are you seeking? (please check 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_33_282'>\n\t\t\t<div class='gchoice gchoice_33_282_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_282' type='radio' value='Muscle gain'  id='choice_33_282_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_282_0' id='label_33_282_0' class='gform-field-label gform-field-label--type-inline'>Muscle gain<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_282_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_282' type='radio' value='Fat loss'  id='choice_33_282_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_282_1' id='label_33_282_1' class='gform-field-label gform-field-label--type-inline'>Fat loss<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_282_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_282' type='radio' value='Improved healing'  id='choice_33_282_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_282_2' id='label_33_282_2' class='gform-field-label gform-field-label--type-inline'>Improved healing<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_282_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_282' type='radio' value='Memory\/cognitive benefits'  id='choice_33_282_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_282_3' id='label_33_282_3' class='gform-field-label gform-field-label--type-inline'>Memory\/cognitive benefits<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_282_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_282' type='radio' value='Better sleep'  id='choice_33_282_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_282_4' id='label_33_282_4' class='gform-field-label gform-field-label--type-inline'>Better sleep<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_282_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_282' type='radio' value='General anti-aging'  id='choice_33_282_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_282_5' id='label_33_282_5' class='gform-field-label gform-field-label--type-inline'>General anti-aging<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_282_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_282' type='radio' value='Other'  id='choice_33_282_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_282_6' id='label_33_282_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_33_281\" 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 any of the following apply to you? Please 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_33_281'>\n\t\t\t<div class='gchoice gchoice_33_281_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_281' type='radio' value='Active cancer diagnosis'  id='choice_33_281_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_281_0' id='label_33_281_0' class='gform-field-label gform-field-label--type-inline'>Active cancer diagnosis<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_281_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_281' type='radio' value='Disease of the pituitary gland'  id='choice_33_281_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_281_1' id='label_33_281_1' class='gform-field-label gform-field-label--type-inline'>Disease of the pituitary gland<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_281_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_281' type='radio' value='Untreated hypothyroidism'  id='choice_33_281_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_281_2' id='label_33_281_2' class='gform-field-label gform-field-label--type-inline'>Untreated hypothyroidism<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_281_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_281' type='radio' value='Uncontrolled diabetes'  id='choice_33_281_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_281_3' id='label_33_281_3' class='gform-field-label gform-field-label--type-inline'>Uncontrolled diabetes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_281_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_281' type='radio' value='Intracranial lesion\/tumor'  id='choice_33_281_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_281_4' id='label_33_281_4' class='gform-field-label gform-field-label--type-inline'>Intracranial lesion\/tumor<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_281_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_281' type='radio' value='HeartFailure'  id='choice_33_281_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_281_5' id='label_33_281_5' class='gform-field-label gform-field-label--type-inline'>HeartFailure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_281_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_281' type='radio' value='None of the above'  id='choice_33_281_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_281_6' id='label_33_281_6' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_33_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_33_50'>Is there anything else you want to tell your doctor?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_50' id='input_33_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_33_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_33_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_33_3' class='gform_page' data-js='page-field-id-8' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_33_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_33_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_33_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_33_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_33_59'><div class='gchoice gchoice_33_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_33_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_33_59_1' id='label_33_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_33_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_33_60'><div class='gchoice gchoice_33_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_33_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_33_60_1' id='label_33_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_33_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_33_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_33_4' class='gform_page' data-js='page-field-id-61' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_33_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_33_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_33_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>I consent to receive NAD+ (nicotinamide adenine dinucleotide) therapy from my provider. I understand this is an off-label wellness treatment, not FDA-approved for any specific condition. It may be administered by IV, IM, or subcutaneous injection. Benefits may include improved energy, mood, and focus; side effects may include nausea, flushing, rapid heart rate, or injection site discomfort. Results are not guaranteed. I may stop treatment at any time and have discussed alternatives. I confirm I have no history of cancer, current cancer, or genetic cancer risk. I have disclosed my medical history, will report any side effects, and all questions have been answered.<\/h5><\/div><div id=\"field_33_64\" class=\"gfield gfield--type-signature gfield--input-type-signature nt-signature-box 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_33_64'>Sign here<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_64' id='input_33_64_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_33_64_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_33_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_33_64_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_33_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_33_64_data' name='input_33_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_33_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_33_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_33_5' class='gform_page' data-js='page-field-id-65' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_33_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_33_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_33_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_33_170' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_33_170_1_container' >\n                                        <input type='text' name='input_170.1' id='input_33_170_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                        <label for='input_33_170_1' id='input_33_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_33_170_2_container' >\n                                        <input type='text' name='input_170.2' id='input_33_170_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/>\n                                        <label for='input_33_170_2' id='input_33_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_33_170_3_container' >\n                                    <input type='text' name='input_170.3' id='input_33_170_3' value=''    aria-required='true'   autocomplete=\"address-level2\" \/>\n                                    <label for='input_33_170_3' id='input_33_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_33_170_4_container' >\n                                        <select name='input_170.4' id='input_33_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_33_170_4' id='input_33_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_33_170_5_container' >\n                                    <input type='text' name='input_170.5' id='input_33_170_5' value=''    aria-required='true'   autocomplete=\"postal-code\" \/>\n                                    <label for='input_33_170_5' id='input_33_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_33_170_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_33_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_33_171_copy_values_option_container' class='copy_values_option_container' >\n                                        <input type='checkbox' id='input_33_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_33_171_copy_values_activated' id='input_33_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_33_171' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_33_171_1_container' >\n                                        <input type='text' name='input_171.1' id='input_33_171_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                        <label for='input_33_171_1' id='input_33_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_33_171_2_container' >\n                                        <input type='text' name='input_171.2' id='input_33_171_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/>\n                                        <label for='input_33_171_2' id='input_33_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_33_171_3_container' >\n                                    <input type='text' name='input_171.3' id='input_33_171_3' value=''    aria-required='true'   autocomplete=\"address-level2\" \/>\n                                    <label for='input_33_171_3' id='input_33_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_33_171_4_container' >\n                                        <select name='input_171.4' id='input_33_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_33_171_4' id='input_33_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_33_171_5_container' >\n                                    <input type='text' name='input_171.5' id='input_33_171_5' value=''    aria-required='true'   autocomplete=\"postal-code\" \/>\n                                    <label for='input_33_171_5' id='input_33_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_33_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_33_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_33_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_33_6' class='gform_page' data-js='page-field-id-74' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_33_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_33_273\" 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><fieldset id=\"field_33_248\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-half gfield_price gfield_price_33_248 gfield_product_33_248 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_33_248'>\n\t\t\t<div class='gchoice gchoice_33_248_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_248' type='radio' value='&lt;strong&gt;Nad+ 200mg\/ml in 10 ml&lt;\/strong&gt; Directions: Inject 25-50 units subcutaneously 3 times weekly, or as directed by physician.|185'  id='choice_33_248_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_248_0' id='label_33_248_0' class='gform-field-label gform-field-label--type-inline'><strong>NAD<\/strong> $185\/ - month<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_33_184\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-half 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\"  ><h2>Available Add-ons (Optional)<\/h2><\/div><fieldset id=\"field_33_277\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_price_33_277 gfield_product_33_277 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >L-Glutathione<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_33_277'>\n\t\t\t<div class='gchoice gchoice_33_277_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_277' type='radio' value='&lt;strong&gt;L-Glutathione (Reduced) 200mg\/ml in 30ml vial&lt;\/strong&gt;Directions: Inject subcutaneously as directed by physician.|135'  id='choice_33_277_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_277_0' id='label_33_277_0' class='gform-field-label gform-field-label--type-inline'><strong>L-Glutathione <\/strong> $135\/ - month<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_33_275\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_price_33_275 gfield_product_33_275 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_33_275'>\n\t\t\t<div class='gchoice gchoice_33_275_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_275' type='radio' value='&lt;strong&gt;B12&lt;\/strong&gt; $79 one month supply IM|79'  id='choice_33_275_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_275_0' id='label_33_275_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_33_285\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_price_33_285 gfield_product_33_285 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Lipo-b<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_33_285'>\n\t\t\t<div class='gchoice gchoice_33_285_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_285' type='radio' value='&lt;strong&gt;lipo-b&lt;\/strong&gt; $90 one month supply|90'  id='choice_33_285_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_285_0' id='label_33_285_0' class='gform-field-label gform-field-label--type-inline'><strong>Lipo-b<\/strong> $90 one month supply<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_33_276\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_price_33_276 gfield_product_33_276 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_33_276'>\n\t\t\t<div class='gchoice gchoice_33_276_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_276' type='radio' value='&lt;strong&gt;B12&lt;\/strong&gt; $79 one month supply IM|30'  id='choice_33_276_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_276_0' id='label_33_276_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_33_284\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_price_33_284 gfield_product_33_284 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sermorelin<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_33_284'>\n\t\t\t<div class='gchoice gchoice_33_284_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_284' type='radio' value='&lt;strong&gt;Sermorelin 3ml - muscle building&lt;\/strong&gt; Directions: Inject subcutaneously (under the skin) as prescribed by your healthcare provider.|165'  id='choice_33_284_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_284_0' id='label_33_284_0' class='gform-field-label gform-field-label--type-inline'><strong>Sermorelin 3ml - muscle building<\/strong> $165<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_33_284_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_284' type='radio' value='&lt;strong&gt;Sermorelin 10ml - muscle building&lt;\/strong&gt; Directions: Inject subcutaneously (under the skin) as prescribed by your healthcare provider.|399'  id='choice_33_284_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_284_1' id='label_33_284_1' class='gform-field-label gform-field-label--type-inline'><strong>Sermorelin 10ml - muscle building<\/strong> $399<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_33_195\" class=\"gfield gfield--type-product gfield--input-type-hiddenproduct gfield--width-full gform_hidden gfield_price gfield_price_33_195 gfield_product_33_195 gfield_hidden_product 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_33_195_1'>Product Name<\/label><div class='ginput_container ginput_container_product_price_hidden'><input type='hidden' name='input_195.3' value='1' id='ginput_quantity_33_195' class='gform_hidden' \/><input type='hidden' name='input_195.1' value='Product Name' class='gform_hidden' \/><input name='input_195.2' id='ginput_base_price_33_195' type='hidden' value='$0.00' class='gform_hidden ginput_amount' \/><\/div><div class='gfield_description' id='gfield_description_33_195'><p>The benefits of NAD+ injections can vary, most patients report feeling energetic, mental clarity, improved mood and <\/p>\n<\/div><\/div><div id=\"field_33_274\" 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_33_274'>Pharmacy Routing - Specialty Rx Care<\/label><div class='ginput_container ginput_container_select'><select name='input_274' id='input_33_274' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Pharmacy Routing - Specialty Rx Care' selected='selected'>Pharmacy Routing - Specialty Rx Care<\/option><\/select><\/div><\/div><div id=\"field_33_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>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_33_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_33_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_33_7' class='gform_page' data-js='page-field-id-183' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_33_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_33_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_33_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_hidden\"  ><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_33_154\" class=\"gfield gfield--type-shipping gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_shipping gfield_shipping_33 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_33_154'>\n\t\t\t<div class='gchoice gchoice_33_154_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Standard Shipping|25'  id='choice_33_154_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_33_154\"   \/>\n\t\t\t\t\t<label for='choice_33_154_0' id='label_33_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_33_154_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Standard Shipping with Insurance|35'  id='choice_33_154_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_33_154_1' id='label_33_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_33_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_33_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_33_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_33_8' class='gform_page' data-js='page-field-id-181' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_33_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_33_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_33_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_33'>Have a Promo Code?<\/label><div class='ginput_container' id='gf_coupons_container_33'><div class='ginput_container_coupon'><input id='gf_coupon_code_33' class='gf_coupon_code' onkeyup='DisableApplyButton(33);' onchange='DisableApplyButton(33);' onpaste='setTimeout(function(){DisableApplyButton(33);}, 50);' type='text'    \/><input type='button' disabled='disabled' onclick='ApplyCouponCode(33);' 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_33' name='input_148' value=''  \/><input type='hidden' id='gf_total_no_discount_33'\/><input type='hidden' id='gf_coupons_33' name='gf_coupons_33' value='' \/><\/div><\/div><div id=\"field_33_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\"  ><h3>Selected Add-ons<\/h3>\n<ul id=\"selected-addons\"><\/ul>\n<\/div><div id=\"field_33_179\" class=\"gfield gfield--type-total gfield--input-type-total gfield--width-full gfield_price gfield_price_33_ gfield_total gfield_total_33_ 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_33_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_33_179' value='$0.00' class='gform-text-input-reset ginput_total ginput_total_33' \/>\n\t\t\t\t\t\t<\/div><\/div><fieldset id=\"field_33_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_33_142'><span class='ginput_full gform-grid-col' id='input_33_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_33_142_supported_creditcards'>Supported Credit Cards: American Express, Discover, MasterCard, Visa<\/span><\/div>\n                                    <input type='text' name='input_142.1' id='input_33_142_1' value=''   onchange='gformMatchCard(\"input_33_142_1\");' onkeyup='gformMatchCard(\"input_33_142_1\");' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='true'  \/>\n                                    <label for='input_33_142_1' id='input_33_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_33_142_2_container'>\n                                            <fieldset class='ginput_cardinfo_left gform-grid-col' id='input_33_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_33_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_33_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_33_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_33_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_33_142_2_cardinfo_right'>\n                                                <input type='text' name='input_142.3' id='input_33_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_33_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_33_142_5_container'>\n                                            <input type='text' name='input_142.5' id='input_33_142_5' value=''    aria-required='false'  \/>\n                                            <label for='input_33_142_5' id='input_33_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_33' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input 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