{"id":30984,"date":"2023-03-31T13:02:05","date_gmt":"2023-03-31T11:02:05","guid":{"rendered":"https:\/\/yuboost.com\/medical-survey\/"},"modified":"2023-03-31T14:39:39","modified_gmt":"2023-03-31T12:39:39","slug":"medical-survey","status":"publish","type":"page","link":"https:\/\/yuboost.com\/en\/medical-survey\/","title":{"rendered":"Medical survey"},"content":{"rendered":"<h1>Pre-injection medical survey<\/h1>\n<div>\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_3' style='display:none'><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_3' id='gform_3'  action='\/en\/wp-json\/wp\/v2\/pages\/30984#gf_3' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_3_17\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Personal information<\/h3><\/div><fieldset id=\"field_3_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your full name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_1'>\n                            \n                            <span id='input_3_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_3_1_3' class='gform-field-label gform-field-label--type-sub '>Name<\/label>\n                                                    <input type='text' name='input_1.3' id='input_3_1_3' value='' tabindex='50'  aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            \n                            <span id='input_3_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_3_1_6' class='gform-field-label gform-field-label--type-sub '>Last name<\/label>\n                                                            <input type='text' name='input_1.6' id='input_3_1_6' value='' tabindex='52'  aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_57'>Height (cm)<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_3_57' type='text' value='' class='large'   tabindex='54'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_58\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_58'>Weight (kg)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_3_58' type='text' value='' class='large'   tabindex='55'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_50\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_50'>Birth date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_50' id='input_3_50' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon' tabindex='56'  placeholder='dd-mm-yyyy' aria-describedby=\"input_3_50_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_50_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_50' class='gform_hidden' value='https:\/\/yuboost.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_3_4\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your 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_city has_zip has_country ginput_container_address gform-grid-row' id='input_3_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_4_1_container' >\n                                        <label for='input_3_4_1' id='input_3_4_1_label' class='gform-field-label gform-field-label--type-sub '>Address<\/label>\n                                        <input type='text' name='input_4.1' id='input_3_4_1' value='' tabindex='57'   aria-required='true'   autocomplete=\"address-line1\" \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_4_3_container' >\n                                    <label for='input_3_4_3' id='input_3_4_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_4.3' id='input_3_4_3' value='' tabindex='58'   aria-required='true'   autocomplete=\"address-level2\" \/>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_4.4' id='input_3_4_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_3_4_5_container' >\n                                    <label for='input_3_4_5' id='input_3_4_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP code<\/label>\n                                    <input type='text' name='input_4.5' id='input_3_4_5' value='' tabindex='59'   aria-required='true'   autocomplete=\"postal-code\" \/>\n                                <\/span><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_3_4_6_container' >\n                                        <label for='input_3_4_6' id='input_3_4_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                        <select name='input_4.6' id='input_3_4_6' tabindex='60'  aria-required='true'   autocomplete=\"country-name\" ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option> <\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_3_5\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_5'>Your 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_5' id='input_3_5' type='tel' value='' class='medium' tabindex='61'  aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/div><\/div><div id=\"field_3_2\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_2'>Your e-mail<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_2' id='input_3_2' type='email' value='' class='medium' tabindex='62'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_46\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_3_32\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_3col gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >1. Reason for consultation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_3_32'> (multiple choices possible)<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_32'><div class='gchoice gchoice_3_32_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.1' type='checkbox'  value='Chronic fatigue \/ Burnout'  id='choice_3_32_1' tabindex='63'  aria-describedby=\"gfield_description_3_32\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_1' id='label_3_32_1' class='gform-field-label gform-field-label--type-inline'>Chronic fatigue \/ Burnout<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.2' type='checkbox'  value='Stress \/ Sleep disorders'  id='choice_3_32_2' tabindex='64'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_2' id='label_3_32_2' class='gform-field-label gform-field-label--type-inline'>Stress \/ Sleep disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.3' type='checkbox'  value='Detox \/ Digestive issues'  id='choice_3_32_3' tabindex='65'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_3' id='label_3_32_3' class='gform-field-label gform-field-label--type-inline'>Detox \/ Digestive issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.4' type='checkbox'  value='Weak immunity \/ Recurrent infections'  id='choice_3_32_4' tabindex='66'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_4' id='label_3_32_4' class='gform-field-label gform-field-label--type-inline'>Weak immunity \/ Recurrent infections<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.5' type='checkbox'  value='Migraine or chronic pain'  id='choice_3_32_5' tabindex='67'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_5' id='label_3_32_5' class='gform-field-label gform-field-label--type-inline'>Migraine or chronic pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.6' type='checkbox'  value='Concentration \/ Memory disorders'  id='choice_3_32_6' tabindex='68'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_6' id='label_3_32_6' class='gform-field-label gform-field-label--type-inline'>Concentration \/ Memory disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.7' type='checkbox'  value='Sports preparation or recovery'  id='choice_3_32_7' tabindex='69'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_7' id='label_3_32_7' class='gform-field-label gform-field-label--type-inline'>Sports preparation or recovery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.8' type='checkbox'  value='Skin problems'  id='choice_3_32_8' tabindex='70'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_8' id='label_3_32_8' class='gform-field-label gform-field-label--type-inline'>Skin problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.9' type='checkbox'  value='Hair loss or brittle nails'  id='choice_3_32_9' tabindex='71'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_9' id='label_3_32_9' class='gform-field-label gform-field-label--type-inline'>Hair loss or brittle nails<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.11' type='checkbox'  value='Anti-aging \/ Longevity goal'  id='choice_3_32_11' tabindex='72'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_11' id='label_3_32_11' class='gform-field-label gform-field-label--type-inline'>Anti-aging \/ Longevity goal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.12' type='checkbox'  value='Other (please specify below)'  id='choice_3_32_12' tabindex='73'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_12' id='label_3_32_12' class='gform-field-label gform-field-label--type-inline'>Other (please specify below)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_24\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_24'>If other(s), please specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_3_24' type='text' value='' class='medium'   tabindex='74'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_61\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. Previous experience with intravenous infusions<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_3_61'>\n\t\t\t<div class='gchoice gchoice_3_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='None'  id='choice_3_61_0' onchange='gformToggleRadioOther( this )'  tabindex='75'  \/>\n\t\t\t\t\t<label for='choice_3_61_0' id='label_3_61_0' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Yes, well tolerated'  id='choice_3_61_1' onchange='gformToggleRadioOther( this )'  tabindex='76'  \/>\n\t\t\t\t\t<label for='choice_3_61_1' id='label_3_61_1' class='gform-field-label gform-field-label--type-inline'>Yes, well tolerated<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_61_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Yes, but with side effects'  id='choice_3_61_2' onchange='gformToggleRadioOther( this )'  tabindex='77'  \/>\n\t\t\t\t\t<label for='choice_3_61_2' id='label_3_61_2' class='gform-field-label gform-field-label--type-inline'>Yes, but with side effects<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_62\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_62'>Please specify side effects<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_3_62' type='text' value='' class='medium'   tabindex='78'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_63\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >3. Known medical history<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_3_63'>Please tick any situation that applies to you:<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_63'><div class='gchoice gchoice_3_63_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.1' type='checkbox'  value='Known allergy to vitamins'  id='choice_3_63_1' tabindex='79'  aria-describedby=\"gfield_description_3_63\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_63_1' id='label_3_63_1' class='gform-field-label gform-field-label--type-inline'>Known allergy to vitamins<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_63_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.2' type='checkbox'  value='Pregnancy or breastfeeding'  id='choice_3_63_2' tabindex='80'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_63_2' id='label_3_63_2' class='gform-field-label gform-field-label--type-inline'>Pregnancy or breastfeeding<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_63_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.3' type='checkbox'  value='High blood pressure'  id='choice_3_63_3' tabindex='81'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_63_3' id='label_3_63_3' class='gform-field-label gform-field-label--type-inline'>High blood pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_63_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.4' type='checkbox'  value='Type 1 or Type 2 diabetes'  id='choice_3_63_4' tabindex='82'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_63_4' id='label_3_63_4' class='gform-field-label gform-field-label--type-inline'>Type 1 or Type 2 diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_63_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.5' type='checkbox'  value='Kidney or liver failure'  id='choice_3_63_5' tabindex='83'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_63_5' id='label_3_63_5' class='gform-field-label gform-field-label--type-inline'>Kidney or liver failure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_63_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.6' type='checkbox'  value='G6PD deficiency'  id='choice_3_63_6' tabindex='84'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_63_6' id='label_3_63_6' class='gform-field-label gform-field-label--type-inline'>G6PD deficiency<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_63_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.7' type='checkbox'  value='Kidney stones'  id='choice_3_63_7' tabindex='85'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_63_7' id='label_3_63_7' class='gform-field-label gform-field-label--type-inline'>Kidney stones<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_63_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.8' type='checkbox'  value='Asthma \/ Eczema'  id='choice_3_63_8' tabindex='86'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_63_8' id='label_3_63_8' class='gform-field-label gform-field-label--type-inline'>Asthma \/ Eczema<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_63_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.9' type='checkbox'  value='Heart condition'  id='choice_3_63_9' tabindex='87'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_63_9' id='label_3_63_9' class='gform-field-label gform-field-label--type-inline'>Heart condition<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_63_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.11' type='checkbox'  value='Cancer (current or past)'  id='choice_3_63_11' tabindex='88'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_63_11' id='label_3_63_11' class='gform-field-label gform-field-label--type-inline'>Cancer (current or past)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_63_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.12' type='checkbox'  value='Neurological disease (Parkinson\u2019s, epilepsy, MS, etc.)'  id='choice_3_63_12' tabindex='89'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_63_12' id='label_3_63_12' class='gform-field-label gform-field-label--type-inline'>Neurological disease (Parkinson\u2019s, epilepsy, MS, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_63_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.13' type='checkbox'  value='Autoimmune disease'  id='choice_3_63_13' tabindex='90'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_63_13' id='label_3_63_13' class='gform-field-label gform-field-label--type-inline'>Autoimmune disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_63_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.14' type='checkbox'  value='Blood clotting disorder or hemopathy (hemochromatosis or beta-thalassemia)'  id='choice_3_63_14' tabindex='91'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_63_14' id='label_3_63_14' class='gform-field-label gform-field-label--type-inline'>Blood clotting disorder or hemopathy (hemochromatosis or beta-thalassemia)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_63_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.15' type='checkbox'  value='Tuberculosis'  id='choice_3_63_15' tabindex='92'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_63_15' id='label_3_63_15' class='gform-field-label gform-field-label--type-inline'>Tuberculosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_63_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.16' type='checkbox'  value='Active autoimmune disease (lupus, sarcoidosis, scleroderma, etc.)'  id='choice_3_63_16' tabindex='93'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_63_16' id='label_3_63_16' class='gform-field-label gform-field-label--type-inline'>Active autoimmune disease (lupus, sarcoidosis, scleroderma, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_63_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.17' type='checkbox'  value='Other significant medical history'  id='choice_3_63_17' tabindex='94'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_63_17' id='label_3_63_17' class='gform-field-label gform-field-label--type-inline'>Other significant medical history<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_59\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_59'>If other, please specify :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_3_59' type='text' value='' class='medium'   tabindex='95'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. Current treatments<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_3_23'>\n\t\t\t<div class='gchoice gchoice_3_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='I&#039;m currently taking medications or supplements'  id='choice_3_23_0' onchange='gformToggleRadioOther( this )'  tabindex='96'  \/>\n\t\t\t\t\t<label for='choice_3_23_0' id='label_3_23_0' class='gform-field-label gform-field-label--type-inline'>I'm currently taking medications or supplements<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='I am not currently taking any medication'  id='choice_3_23_1' onchange='gformToggleRadioOther( this )'  tabindex='97'  \/>\n\t\t\t\t\t<label for='choice_3_23_1' id='label_3_23_1' class='gform-field-label gform-field-label--type-inline'>I am not currently taking any medication<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_64\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_64'>List all medications or supplements taken regularly:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_3_64' type='text' value='' class='medium'   tabindex='98'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_65\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >5. Known allergies<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_3_65'><div class='gchoice gchoice_3_65_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.1' type='checkbox'  value='None'  id='choice_3_65_1' tabindex='99'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_65_1' id='label_3_65_1' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_65_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.2' type='checkbox'  value='Drug-related (e.g.: penicillin, sulfonamides, etc.)'  id='choice_3_65_2' tabindex='100'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_65_2' id='label_3_65_2' class='gform-field-label gform-field-label--type-inline'>Drug-related (e.g.: penicillin, sulfonamides, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_65_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.3' type='checkbox'  value='Pollen or Food-related (e.g.: grasses, eggs, etc.)'  id='choice_3_65_3' tabindex='101'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_65_3' id='label_3_65_3' class='gform-field-label gform-field-label--type-inline'>Pollen or Food-related (e.g.: grasses, eggs, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_65_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.4' type='checkbox'  value='Other (insect bites, latex, etc.)'  id='choice_3_65_4' tabindex='102'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_65_4' id='label_3_65_4' class='gform-field-label gform-field-label--type-inline'>Other (insect bites, latex, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_66\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_66'>If other, please specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_3_66' type='text' value='' class='medium'   tabindex='103'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_40\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  >\t<ul>\n\t\t<li>Patients with Chronic KidneyDisease (CKD) and\/or with heart problems (CHF, Atrial Fibrillation, CAD etc.) Patients that have a history of seizures.<\/li>\n\t\t<li>Cancer patients \u2013 must have records and order from treating Oncologist\/PCP prior to administering IV infusion.<\/li>\n\t\t<li>Patients under 18 and over 75 years.<\/li>\n\t\t<li>Pregnant Woman (except the \"Basic Hydratation\" perfusion).<\/li>\n\t\t<li>Patients who require an in-person exam due to severe symptoms(feverish state, decline of general condition).<\/li>\n\t\t<li>Patients who already had a side effect like allergic reaction to Vitamin IV perfusion or any other kind of vitamin injection.<\/li>\n\t\t<li>Patients that take benzodiazepine and anti- seizure medication.<\/li>\n\t<\/ul>\n\t<p>If at any point your nurse has a reason to believe that you are not suitable for IV infusion, the nurse will postpone the treatment or will propose you to do the first injection in the Lausanne's clinic under close medical monitoring.<\/p>\n<\/body><\/div><div id=\"field_3_44\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_3_45\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>I hereby certify that the information provided is complete and I undertake to notify him of any subsequent changes in my health status.<\/p><\/div><fieldset id=\"field_3_48\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I confirm that the medical informations are accurate<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_3_48'><div class='gchoice gchoice_3_48_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.1' type='checkbox'  value='Yes, I confirm'  id='choice_3_48_1' tabindex='104'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_48_1' id='label_3_48_1' class='gform-field-label gform-field-label--type-inline'>Yes, I confirm<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_51\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_3_52\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2> Consent to medical care <\/h2>\t<p>a. I hereby authorize the health care providers of Yuboost, and their staff, to perform any medical procedures and medical care which in their professional judgment is deemed necessary to diagnose and\/or treat the conditions that have brought about my seeking medical care services. I acknowledge that no guarantees are made to me concerning the outcomes of the treatment performed.<\/p>\n\t<p>b. I agree that the staff of Yuboost has communicated to me the risks and benefits associated with each treatment I am agreeing to undertake and I have had an opportunity to ask the practitioner any questions I have regarding the risk associated with the treatment I am undertaking. Knowing each of those risks, I am agreeing to proceed with these services.<\/p>\n\t<p>c. I accept that in the event of an accident involving a sting, a blood splash or any other injury involving blood contact, Yuboost's medical staff may carry out serological tests (blood screening) for hepatitis B, hepatitis C and HIV. This will be paid for by Yuboost.<\/p><\/div><fieldset id=\"field_3_53\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you confirm that you validate the consent to medical care?<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_3_53'><div class='gchoice gchoice_3_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='Yes, I confirm'  id='choice_3_53_1' tabindex='105'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_53_1' id='label_3_53_1' class='gform-field-label gform-field-label--type-inline'>Yes, I confirm<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >By subscribing to our newsletter, you\u2019ll enjoy exclusive offers reserved for our members, personalized health tips, and privileged access to all Yuboost updates.<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_3_56'>\n\t\t\t<div class='gchoice gchoice_3_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Yes, I want to enjoy exclusive offers, health tips, and Yuboost updates'  id='choice_3_56_0' onchange='gformToggleRadioOther( this )'  tabindex='106'  \/>\n\t\t\t\t\t<label for='choice_3_56_0' id='label_3_56_0' class='gform-field-label gform-field-label--type-inline'>Yes, I want to enjoy exclusive offers, health tips, and Yuboost updates<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='No, thank you'  id='choice_3_56_1' onchange='gformToggleRadioOther( this )'  tabindex='107'  \/>\n\t\t\t\t\t<label for='choice_3_56_1' id='label_3_56_1' class='gform-field-label gform-field-label--type-inline'>No, thank you<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_54\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date<\/legend><div id='input_3_54' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_3_54_2_container'>\n                                            <label for='input_3_54_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                            <input type='number' maxlength='2' name='input_54[]' id='input_3_54_2' value='' tabindex='108'  aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_3_54_1_container'>\n                                        <label for='input_3_54_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <input type='number' maxlength='2' name='input_54[]' id='input_3_54_1' value='' tabindex='109'  aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_3_54_3_container'>\n                                            <label for='input_3_54_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                            <input type='number' maxlength='4' name='input_54[]' id='input_3_54_3' value='' tabindex='110'  aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_3_55\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_55'>Signature<\/label><input type='hidden' value='' name='input_55' id='input_3_55_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_55_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_3_55' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/yuboost.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_3_55_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_3_55_resetbutton' 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