{"id":2242,"date":"2026-02-21T17:01:15","date_gmt":"2026-02-21T23:01:15","guid":{"rendered":"https:\/\/simplefixrx.com\/?page_id=2242"},"modified":"2026-02-21T17:01:15","modified_gmt":"2026-02-21T23:01:15","slug":"dense-questionnaire","status":"publish","type":"page","link":"https:\/\/simplefixrx.com\/es\/dense-questionnaire\/","title":{"rendered":"Dense- 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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class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>8<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_12' style='width:12%;'><span>12%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_35_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_35' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_35_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_35_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_35_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_35_1' type='text' value='' class='large'    placeholder='First Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_35_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_35_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_35_2' type='text' value='' class='large'    placeholder='Last Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_35_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_35_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_35_3' type='email' value='' class='large'   placeholder='Email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_35_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_35_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_35_4' type='tel' value='' class='large'  placeholder='Phone' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_35_253\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half 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_35_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_35_253' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_35_260\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half 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_35_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_35_260' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_35_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_35_5' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_35_5_1_container'>\n                                            <input type='number' maxlength='2' name='input_5[]' id='input_35_5_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_35_5_1' class='gform-field-label gform-field-label--type-sub '>Month<\/label>\n                                 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  <\/div>\n                                   <\/div><\/fieldset><div id=\"field_35_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_35_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_35_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_35_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_35_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_35_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_35_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_35_228'>Google Ad Source<\/label><div class='ginput_container ginput_container_text'><input name='input_228' id='input_35_228' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_35_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_35_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_35_2' class='gform_page' data-js='page-field-id-169' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_35_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_35_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_35_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 satisfied are you with your hair overall?<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_35_250'>\n\t\t\t<div class='gchoice gchoice_35_250_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_250' type='radio' value='Sedentary'  id='choice_35_250_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_250_0' id='label_35_250_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_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_35_250_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_250_1' id='label_35_250_1' class='gform-field-label gform-field-label--type-inline'>A little bit<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_250_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_250' type='radio' value='Somewhat Active'  id='choice_35_250_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_250_2' id='label_35_250_2' class='gform-field-label gform-field-label--type-inline'>Somewhat<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_250_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_250' type='radio' value='Athletic'  id='choice_35_250_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_250_3' id='label_35_250_3' class='gform-field-label gform-field-label--type-inline'>Quite a bit<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_250_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_250' type='radio' value='Competitive\/Biohacker'  id='choice_35_250_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_250_4' id='label_35_250_4' class='gform-field-label gform-field-label--type-inline'>Very<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_35_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >What are your top-priority goals for hair loss treatment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_35_24'>\n\t\t\t<div class='gchoice gchoice_35_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='I want to prevent further hair loss'  id='choice_35_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_24_0' id='label_35_24_0' class='gform-field-label gform-field-label--type-inline'>I want to prevent further hair loss<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='I want to regrow hair'  id='choice_35_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_24_1' id='label_35_24_1' class='gform-field-label gform-field-label--type-inline'>I want to regrow hair<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_24_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='I want fuller thicker-looking hair,'  id='choice_35_24_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_24_2' id='label_35_24_2' class='gform-field-label gform-field-label--type-inline'>I want fuller thicker-looking hair,<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_24_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='I have a full head of hair I&#039;d like to maintain'  id='choice_35_24_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_24_3' id='label_35_24_3' class='gform-field-label gform-field-label--type-inline'>I have a full head of hair I'd like to maintain<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_35_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' >Where are you noticing hair loss or thinning?<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_35_46'>\n\t\t\t<div class='gchoice gchoice_35_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Both hairline and crown'  id='choice_35_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_46_0' id='label_35_46_0' class='gform-field-label gform-field-label--type-inline'>Both hairline and crown<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Receding hairline (along my forehead or temples)'  id='choice_35_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_46_1' id='label_35_46_1' class='gform-field-label gform-field-label--type-inline'>Receding hairline (along my forehead or temples)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_46_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Thinning crown (top of my head)'  id='choice_35_46_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_46_2' id='label_35_46_2' class='gform-field-label gform-field-label--type-inline'>Thinning crown (top of my head)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_46_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Overall thinning'  id='choice_35_46_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_46_3' id='label_35_46_3' class='gform-field-label gform-field-label--type-inline'>Overall thinning<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_46_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Random golf-ball size bald patches scattered all over scalp'  id='choice_35_46_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_46_4' id='label_35_46_4' class='gform-field-label gform-field-label--type-inline'>Random golf-ball size bald patches scattered all over scalp<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_46_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Nowhere yet, but I&#039;d like to prevent future hair loss'  id='choice_35_46_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_46_5' id='label_35_46_5' class='gform-field-label gform-field-label--type-inline'>Nowhere yet, but I'd like to prevent future hair loss<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_35_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 treated your hair loss with medication?<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_35_261'>\n\t\t\t<div class='gchoice gchoice_35_261_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_261' type='radio' value='Yes'  id='choice_35_261_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_261_0' id='label_35_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_35_261_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_261' type='radio' value='No'  id='choice_35_261_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_261_1' id='label_35_261_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_35_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' >What treatments did you receive?<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_35_255'>\n\t\t\t<div class='gchoice gchoice_35_255_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_255' type='radio' value='Oral minoxidil'  id='choice_35_255_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_255_0' id='label_35_255_0' class='gform-field-label gform-field-label--type-inline'>Oral minoxidil<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_255_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_255' type='radio' value='Topical minoxidil or Rogaine'  id='choice_35_255_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_255_1' id='label_35_255_1' class='gform-field-label gform-field-label--type-inline'>Topical minoxidil or Rogaine<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_255_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_255' type='radio' value='Oral Finasteride or Propecia'  id='choice_35_255_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_255_2' id='label_35_255_2' class='gform-field-label gform-field-label--type-inline'>Oral Finasteride or Propecia<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_255_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_255' type='radio' value='Topical finasteride'  id='choice_35_255_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_255_3' id='label_35_255_3' class='gform-field-label gform-field-label--type-inline'>Topical finasteride<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_255_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_255' type='radio' value='Steroid injections in the scalp'  id='choice_35_255_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_255_4' id='label_35_255_4' class='gform-field-label gform-field-label--type-inline'>Steroid injections in the scalp<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_255_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_255' type='radio' value='Other'  id='choice_35_255_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_255_5' id='label_35_255_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_35_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_35_262'>Please tell us more about your treatment experience (effectiveness, side effects, etc.).<\/label><div class='ginput_container ginput_container_text'><input name='input_262' id='input_35_262' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_35_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 noticed any of the following?<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_35_257'>\n\t\t\t<div class='gchoice gchoice_35_257_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_257' type='radio' value='Redness or rashes on scalp'  id='choice_35_257_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_257_0' id='label_35_257_0' class='gform-field-label gform-field-label--type-inline'>Redness or rashes on scalp<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_257_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_257' type='radio' value='Pain, soreness, burning, and\/or tingling in areas of hair loss'  id='choice_35_257_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_257_1' id='label_35_257_1' class='gform-field-label gform-field-label--type-inline'>Pain, soreness, burning, and\/or tingling in areas of hair loss<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_257_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_257' type='radio' value='Recurrent pus bumps or open sores on scalp'  id='choice_35_257_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_257_2' id='label_35_257_2' class='gform-field-label gform-field-label--type-inline'>Recurrent pus bumps or open sores on scalp<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_257_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_257' type='radio' value='Partial or complete loss of eyebrows or eyelashes'  id='choice_35_257_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_257_3' id='label_35_257_3' class='gform-field-label gform-field-label--type-inline'>Partial or complete loss of eyebrows or eyelashes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_257_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_257' type='radio' value='Loss of body hair'  id='choice_35_257_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_257_4' id='label_35_257_4' class='gform-field-label gform-field-label--type-inline'>Loss of body hair<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_257_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_257' type='radio' value='None of the above'  id='choice_35_257_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_257_5' id='label_35_257_5' 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_35_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' >Have you ever been diagnosed with or treated for high or low blood pressure?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_35_265'><div class='gchoice gchoice_35_265_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_265.1' type='checkbox'  value='No'  id='choice_35_265_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_265_1' id='label_35_265_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_265_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_265.2' type='checkbox'  value='Yes, I have been diagnosed or treated for high blood pressure'  id='choice_35_265_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_265_2' id='label_35_265_2' class='gform-field-label gform-field-label--type-inline'>Yes, I have been diagnosed or treated for high blood pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_265_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_265.3' type='checkbox'  value='Yes, I have been diagnosed or treated for low blood pressure'  id='choice_35_265_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_265_3' id='label_35_265_3' class='gform-field-label gform-field-label--type-inline'>Yes, I have been diagnosed or treated for low blood pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_265_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_265.4' type='checkbox'  value='I&#039;m not sure'  id='choice_35_265_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_265_4' id='label_35_265_4' class='gform-field-label gform-field-label--type-inline'>I'm not sure<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_35_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, or have you ever had, any of the following 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_35_258'>\n\t\t\t<div class='gchoice gchoice_35_258_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='Heart failure'  id='choice_35_258_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_258_0' id='label_35_258_0' class='gform-field-label gform-field-label--type-inline'>Heart failure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_258_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='Pericarditis'  id='choice_35_258_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_258_1' id='label_35_258_1' class='gform-field-label gform-field-label--type-inline'>Pericarditis<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_258_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='Benign Prostatic Hyperplasia'  id='choice_35_258_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_258_2' id='label_35_258_2' class='gform-field-label gform-field-label--type-inline'>Benign Prostatic Hyperplasia<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_258_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='Repeated chest pain or tightness, also called angina, Arrhythmia or abnormal heart rhythm'  id='choice_35_258_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_258_3' id='label_35_258_3' class='gform-field-label gform-field-label--type-inline'>Repeated chest pain or tightness, also called angina, Arrhythmia or abnormal heart rhythm<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_258_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='Coronary artery disease, or narrowing of the heart vessels'  id='choice_35_258_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_258_4' id='label_35_258_4' class='gform-field-label gform-field-label--type-inline'>Coronary artery disease, or narrowing of the heart vessels<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_258_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='Coronary bypass surgery'  id='choice_35_258_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_258_5' id='label_35_258_5' class='gform-field-label gform-field-label--type-inline'>Coronary bypass surgery<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_258_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='Heart attack'  id='choice_35_258_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_258_6' id='label_35_258_6' class='gform-field-label gform-field-label--type-inline'>Heart attack<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_258_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='Stroke'  id='choice_35_258_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_258_7' id='label_35_258_7' class='gform-field-label gform-field-label--type-inline'>Stroke<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_258_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='Pheochromocytoma (adrenal gland tumor)'  id='choice_35_258_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_258_8' id='label_35_258_8' class='gform-field-label gform-field-label--type-inline'>Pheochromocytoma (adrenal gland tumor)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_258_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='Pulmonary hypertension'  id='choice_35_258_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_258_9' id='label_35_258_9' class='gform-field-label gform-field-label--type-inline'>Pulmonary hypertension<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_258_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='Prostate cancer'  id='choice_35_258_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_258_10' id='label_35_258_10' class='gform-field-label gform-field-label--type-inline'>Prostate cancer<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_258_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='Kidney disease'  id='choice_35_258_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_258_11' id='label_35_258_11' 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_35_258_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='Liver disease'  id='choice_35_258_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_258_12' id='label_35_258_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_35_258_13'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='Erectile Dysfunction'  id='choice_35_258_13' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_258_13' id='label_35_258_13' class='gform-field-label gform-field-label--type-inline'>Erectile Dysfunction<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_258_14'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='Anxiety'  id='choice_35_258_14' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_258_14' id='label_35_258_14' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_258_15'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='Depression'  id='choice_35_258_15' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_258_15' id='label_35_258_15' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_258_16'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='Eczema'  id='choice_35_258_16' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_258_16' id='label_35_258_16' class='gform-field-label gform-field-label--type-inline'>Eczema<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_258_17'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='None of the above'  id='choice_35_258_17' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_258_17' id='label_35_258_17' 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_35_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_35_32'>Please list any prescription medications, over-the-counter medications, vitamins, dietary supplements, and topical creams you are currently taking or using, including dosages. Please type N\/A if none.<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_35_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_35_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' >Are you allergic to any of the following? 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_35_266'>\n\t\t\t<div class='gchoice gchoice_35_266_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_266' type='radio' value='Finasteride (oral or topical)'  id='choice_35_266_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_266_0' id='label_35_266_0' class='gform-field-label gform-field-label--type-inline'>Finasteride (oral or topical)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_266_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_266' type='radio' value='Minoxidil (oral or topical)'  id='choice_35_266_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_266_1' id='label_35_266_1' class='gform-field-label gform-field-label--type-inline'>Minoxidil (oral or topical)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_266_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_266' type='radio' value='Ketoconazole (oral or topical)'  id='choice_35_266_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_266_2' id='label_35_266_2' class='gform-field-label gform-field-label--type-inline'>Ketoconazole (oral or topical)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_266_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_266' type='radio' value='Latanoprost'  id='choice_35_266_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_266_3' id='label_35_266_3' class='gform-field-label gform-field-label--type-inline'>Latanoprost<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_35_266_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_266' type='radio' value='None of the above'  id='choice_35_266_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_266_4' id='label_35_266_4' 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_35_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_35_259'>Please list all of your known allergies. Please type N\/A if none.<\/label><div class='ginput_container ginput_container_text'><input name='input_259' id='input_35_259' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_35_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_35_50'>Is there anything else you want to tell your doctor? Please leave your message to your doctor here.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_50' id='input_35_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_35_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_35_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_35_3' class='gform_page' data-js='page-field-id-8' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_35_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_35_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_35_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_35_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_35_59'><div class='gchoice gchoice_35_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_35_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_59_1' id='label_35_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_35_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_35_60'><div class='gchoice gchoice_35_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_35_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_60_1' id='label_35_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_35_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_35_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_35_4' class='gform_page' data-js='page-field-id-61' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_35_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_35_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_35_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 DENSE Hair Growth therapy from my provider. By submitting this request, I acknowledge that I am requesting a medical evaluation for a prescribed hair serum. I understand that SimpleFix and its affiliates do not make medical decisions and that a licensed healthcare provider will determine if this treatment is appropriate for me based on my medical history and health status. If I am not deemed a suitable candidate, my request will be voided, and I will not be charged. I consent to this process and to the review of my information for the purpose of determining treatment eligibility.<\/h5><\/div><div id=\"field_35_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_35_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_35_64_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_35_64_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_35_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_35_64_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_35_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_35_64_data' name='input_35_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_35_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_35_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_35_5' class='gform_page' data-js='page-field-id-65' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_35_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_35_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_35_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_35_170' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_35_170_1_container' >\n                                        <input type='text' name='input_170.1' id='input_35_170_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                        <label for='input_35_170_1' id='input_35_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_35_170_2_container' >\n                                        <input type='text' name='input_170.2' id='input_35_170_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/>\n                                        <label for='input_35_170_2' id='input_35_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_35_170_3_container' >\n                                    <input type='text' name='input_170.3' id='input_35_170_3' value=''    aria-required='true'   autocomplete=\"address-level2\" \/>\n                                    <label for='input_35_170_3' id='input_35_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_35_170_4_container' >\n                                        <select name='input_170.4' id='input_35_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_35_170_4' id='input_35_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_35_170_5_container' >\n                                    <input type='text' name='input_170.5' id='input_35_170_5' value=''    aria-required='true'   autocomplete=\"postal-code\" \/>\n                                    <label for='input_35_170_5' id='input_35_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_35_170_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_35_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_35_171_copy_values_option_container' class='copy_values_option_container' >\n                                        <input type='checkbox' id='input_35_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_35_171_copy_values_activated' id='input_35_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_35_171' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_35_171_1_container' >\n                                        <input type='text' name='input_171.1' id='input_35_171_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                        <label for='input_35_171_1' id='input_35_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_35_171_2_container' >\n                                        <input type='text' name='input_171.2' id='input_35_171_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/>\n                                        <label for='input_35_171_2' id='input_35_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_35_171_3_container' >\n                                    <input type='text' name='input_171.3' id='input_35_171_3' value=''    aria-required='true'   autocomplete=\"address-level2\" \/>\n                                    <label for='input_35_171_3' id='input_35_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_35_171_4_container' >\n                                        <select name='input_171.4' id='input_35_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_35_171_4' id='input_35_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_35_171_5_container' >\n                                    <input type='text' name='input_171.5' id='input_35_171_5' value=''    aria-required='true'   autocomplete=\"postal-code\" \/>\n                                    <label for='input_35_171_5' id='input_35_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_35_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_35_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_35_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_35_6' class='gform_page' data-js='page-field-id-74' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_35_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_35_267\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-third gfield_price gfield_price_35_267 gfield_product_35_267 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >DENSE - Hair Growth<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_35_267'>\n\t\t\t<div class='gchoice gchoice_35_267_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='&lt;strong&gt;DENSE - Hair Growth - 1 Bottle&lt;\/strong&gt;|159'  id='choice_35_267_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_267_0' id='label_35_267_0' class='gform-field-label gform-field-label--type-inline'><strong> DENSE - Hair Growth - 1 Bottle<\/strong> $159\/ - month<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_35_268\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-third gfield_price gfield_price_35_268 gfield_product_35_268 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' >DENSE - Hair Growth<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_35_268'>\n\t\t\t<div class='gchoice gchoice_35_268_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_268' type='radio' value='&lt;strong&gt;DENSE - Hair Growth - 1 Bottle&lt;\/strong&gt; $159\/ - month|159'  id='choice_35_268_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_268_0' id='label_35_268_0' class='gform-field-label gform-field-label--type-inline'><strong> DENSE - Hair Growth - 1 Bottle<\/strong> $159\/ - month<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_35_184\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-third 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><div id=\"field_35_195\" class=\"gfield gfield--type-product gfield--input-type-hiddenproduct gfield--width-full gform_hidden gfield_price gfield_price_35_195 gfield_product_35_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_35_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_35_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_35_195' type='hidden' value='$0.00' class='gform_hidden ginput_amount' \/><\/div><div class='gfield_description' id='gfield_description_35_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_35_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_35_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_35_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_35_7' class='gform_page' data-js='page-field-id-183' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_35_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_35_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_35_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_35_154\" class=\"gfield gfield--type-shipping gfield--type-choice gfield--input-type-radio gfield--width-full gfield_price gfield_shipping gfield_shipping_35 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_35_154'>\n\t\t\t<div class='gchoice gchoice_35_154_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Standard Shipping|25'  id='choice_35_154_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_35_154\"   \/>\n\t\t\t\t\t<label for='choice_35_154_0' id='label_35_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_35_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_35_154_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_35_154_1' id='label_35_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_35_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_35_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_35_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_35_8' class='gform_page' data-js='page-field-id-181' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div 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