{"id":1539,"date":"2025-06-23T22:07:49","date_gmt":"2025-06-24T03:07:49","guid":{"rendered":"https:\/\/simplefixrx.com\/?page_id=1539"},"modified":"2025-07-25T14:55:36","modified_gmt":"2025-07-25T19:55:36","slug":"nausea","status":"publish","type":"page","link":"https:\/\/simplefixrx.com\/es\/nausea\/","title":{"rendered":"N\u00e1useas"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of 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data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_39' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_39_122\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full nt-step-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Let's Get Started<\/h2><\/div><div id=\"field_39_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_39_1'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_39_1' type='text' value='' class='large'    placeholder='First Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_39_2\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_39_2'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_39_2' type='text' value='' class='large'    placeholder='Last Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_39_3\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_39_3'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_39_3' type='email' value='' class='large'   placeholder='Email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_39_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_39_4'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_39_4' type='tel' value='' class='large'  placeholder='Phone' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_39_253\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_39_253'>Height<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_253' id='input_39_253' type='number' step='any'   value='' class='large'    placeholder='Feet' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_39_272\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_39_272'>Height<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_272' id='input_39_272' type='number' step='any'   value='' class='large'    placeholder='inches' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_39_260\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_39_260'>Weight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_260' id='input_39_260' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_39_5\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield 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' >Date Of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_39_5' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_39_5_1_container'>\n                                            <input type='number' maxlength='2' name='input_5[]' id='input_39_5_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_39_5_1' class='gform-field-label gform-field-label--type-sub '>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_39_5_2_container'>\n                                            <input type='number' maxlength='2' name='input_5[]' id='input_39_5_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_39_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_39_5_3_container'>\n                                            <input type='number' maxlength='4' name='input_5[]' id='input_39_5_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_39_5_3' class='gform-field-label gform-field-label--type-sub '>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_39_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_39_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_39_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_39_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_39_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_39_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_39_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_39_228'>Google Ad Source<\/label><div class='ginput_container ginput_container_text'><input name='input_228' id='input_39_228' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_39_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 id=\"field_39_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_hidden\"  ><h2>Medical History<\/h2><\/div><fieldset id=\"field_39_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_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label' >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_39_250'>\n\t\t\t<div class='gchoice gchoice_39_250_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_250' type='radio' value='Sedentary'  id='choice_39_250_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_39_250_0' id='label_39_250_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_39_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_39_250_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_39_250_1' id='label_39_250_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_39_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_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label' >Do you have any of the following conditions? (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_39_24'>\n\t\t\t<div class='gchoice gchoice_39_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Leber&#039;s optic neuropathy'  id='choice_39_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_39_24_0' id='label_39_24_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_39_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Polycythemia Vera'  id='choice_39_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_39_24_1' id='label_39_24_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_39_24_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Gout'  id='choice_39_24_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_39_24_2' id='label_39_24_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_39_24_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Low potassium levels'  id='choice_39_24_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_39_24_3' id='label_39_24_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_39_24_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Anemia for any reason other than low vitamin B12'  id='choice_39_24_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_39_24_4' id='label_39_24_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_39_24_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Any other blood disorder'  id='choice_39_24_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_39_24_5' id='label_39_24_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_39_24_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value=''  id='choice_39_24_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_39_24_6' id='label_39_24_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_39_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_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_39_262'>Please list all current medical conditions. Please type N\/A if none.<\/label><div class='ginput_container ginput_container_text'><input name='input_262' id='input_39_262' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_39_277\" 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_39_277'>Please list all your current medications, including prescription, over-the-counter, and supplements, including dosages. Please type N\/A if none.<\/label><div class='ginput_container ginput_container_text'><input name='input_277' id='input_39_277' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_39_278\" 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_39_278'>Please list all of your known allergies. Please type N\/A if none.<\/label><div class='ginput_container ginput_container_text'><input name='input_278' id='input_39_278' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_39_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_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label' >Which type of consultation would you prefer?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_39_46'>\n\t\t\t<div class='gchoice gchoice_39_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Email and Text Message (Fastest Option)'  id='choice_39_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_39_46_0' id='label_39_46_0' class='gform-field-label gform-field-label--type-inline'>Email and Text Message (Fastest Option)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_39_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Video'  id='choice_39_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_39_46_1' id='label_39_46_1' class='gform-field-label gform-field-label--type-inline'>Video<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_39_46_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Phone Call'  id='choice_39_46_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_39_46_2' id='label_39_46_2' class='gform-field-label gform-field-label--type-inline'>Phone Call<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_39_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_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_39_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_39_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_next_button_39_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_39_2' class='gform_page' data-js='page-field-id-8' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_39_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_39_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_39_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_39_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_39_59'><div class='gchoice gchoice_39_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_39_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_39_59_1' id='label_39_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_39_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_39_60'><div class='gchoice gchoice_39_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_39_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_39_60_1' id='label_39_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_39_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_39_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_39_3' class='gform_page' data-js='page-field-id-61' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_39_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_39_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_39_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_39_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_39_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_39_64_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_39_64_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_39_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_39_64_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_39_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_39_64_data' name='input_39_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_39_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_39_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_39_4' class='gform_page' data-js='page-field-id-65' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_39_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_39_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_39_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_39_170' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_39_170_1_container' >\n                                        <input type='text' name='input_170.1' id='input_39_170_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                        <label for='input_39_170_1' id='input_39_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_39_170_2_container' >\n                                        <input type='text' name='input_170.2' id='input_39_170_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/>\n                                        <label for='input_39_170_2' id='input_39_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_39_170_3_container' >\n                                    <input type='text' name='input_170.3' id='input_39_170_3' value=''    aria-required='true'   autocomplete=\"address-level2\" \/>\n                                    <label for='input_39_170_3' id='input_39_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_39_170_4_container' >\n                                        <select name='input_170.4' id='input_39_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_39_170_4' id='input_39_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_39_170_5_container' >\n                                    <input type='text' name='input_170.5' id='input_39_170_5' value=''    aria-required='true'   autocomplete=\"postal-code\" \/>\n                                    <label for='input_39_170_5' id='input_39_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_39_170_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_39_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_39_171_copy_values_option_container' class='copy_values_option_container' >\n                                        <input type='checkbox' id='input_39_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_39_171_copy_values_activated' id='input_39_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_39_171' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_39_171_1_container' >\n                                        <input type='text' name='input_171.1' id='input_39_171_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                        <label for='input_39_171_1' id='input_39_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_39_171_2_container' >\n                                        <input type='text' name='input_171.2' id='input_39_171_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/>\n                                        <label for='input_39_171_2' id='input_39_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_39_171_3_container' >\n                                    <input type='text' name='input_171.3' id='input_39_171_3' value=''    aria-required='true'   autocomplete=\"address-level2\" \/>\n                                    <label for='input_39_171_3' id='input_39_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_39_171_4_container' >\n                                        <select name='input_171.4' id='input_39_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_39_171_4' id='input_39_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_39_171_5_container' >\n                                    <input type='text' name='input_171.5' id='input_39_171_5' value=''    aria-required='true'   autocomplete=\"postal-code\" \/>\n                                    <label for='input_39_171_5' id='input_39_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_39_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_39_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_39_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_39_5' class='gform_page' data-js='page-field-id-74' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_39_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_39_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_39_248\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-half gfield_price gfield_price_39_248 gfield_product_39_248 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label' >NAD - Anti- Aging<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_39_248'>\n\t\t\t<div class='gchoice gchoice_39_248_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_248' type='radio' value='&lt;strong&gt;NAD&lt;\/strong&gt; $185\/ - month|185'  id='choice_39_248_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_39_248_0' id='label_39_248_0' class='gform-field-label gform-field-label--type-inline'><strong>NAD<\/strong> $185\/ - month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_39_248_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_248' type='radio' value='&lt;strong&gt;NAD&lt;\/strong&gt; $320\/ - 2 month|320'  id='choice_39_248_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_39_248_1' id='label_39_248_1' class='gform-field-label gform-field-label--type-inline'><strong>NAD<\/strong> $320\/ - 2 month<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_39_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_39_275\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_price_39_275 gfield_product_39_275 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label' >B12<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_39_275'>\n\t\t\t<div class='gchoice gchoice_39_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_39_275_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_39_275_0' id='label_39_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_39_276\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_price_39_276 gfield_product_39_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_39_276'>\n\t\t\t<div class='gchoice gchoice_39_276_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_276' type='radio' value='&lt;strong&gt;4 mg Ondansetron&lt;\/strong&gt; Anti-Nausea Pills, 30-Count - Directions: Take 1 tablet (4 mg) by mouth every 8 hours as needed for nausea and vomiting.|30' checked='checked' id='choice_39_276_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_39_276_0' id='label_39_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><div id=\"field_39_195\" class=\"gfield gfield--type-product gfield--input-type-hiddenproduct gfield--width-full gform_hidden gfield_price gfield_price_39_195 gfield_product_39_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_39_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_39_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_39_195' type='hidden' value='$0.00' class='gform_hidden ginput_amount' \/><\/div><div class='gfield_description' id='gfield_description_39_195'><p>The benefits of B12 injections can vary, most patients reports that it Boosts Energy, Improves Brain Function, Supports Heart Health, Prevent Deficiency, Improves Hair, Skin and Nail health.<\/p>\n<\/div><\/div><div id=\"field_39_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_39_274'>Pharmacy Routing - Specialty Rx Care<\/label><div class='ginput_container ginput_container_select'><select name='input_274' id='input_39_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_39_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_39_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_39_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_39_6' class='gform_page' data-js='page-field-id-183' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_39_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_39_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_39_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><div id=\"field_39_154\" class=\"gfield gfield--type-shipping gfield--input-type-singleshipping gfield--width-full gfield_price gfield_shipping gfield_shipping_39 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_39_154'>Flat-Rate Shipping<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_singleshipping'>\n\t\t\t\t\t<input type='text' readonly class='ginput_shipping_price gform-text-input-reset' id='input_39_154' name='input_154' value='$9.00' \/>\n\t\t\t\t<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_39_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_39_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_39_7' class='gform_page' data-js='page-field-id-181' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_39_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_39_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_39_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_39'>Have a Promo Code?<\/label><div class='ginput_container' id='gf_coupons_container_39'><div class='ginput_container_coupon'><input id='gf_coupon_code_39' class='gf_coupon_code' onkeyup='DisableApplyButton(39);' onchange='DisableApplyButton(39);' onpaste='setTimeout(function(){DisableApplyButton(39);}, 50);' type='text'    \/><input type='button' disabled='disabled' onclick='ApplyCouponCode(39);' 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 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