{"id":417,"date":"2023-02-20T17:45:35","date_gmt":"2023-02-20T17:45:35","guid":{"rendered":"https:\/\/uabmedicine.org\/blogs\/greyform\/?page_id=417"},"modified":"2023-02-20T17:45:35","modified_gmt":"2023-02-20T17:45:35","slug":"uab-eye-care","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/uab-eye-care\/","title":{"rendered":"UAB Eye Care"},"content":{"rendered":"<script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&#038;&#038;(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&#038;&#038;t!=i[e].tag||null!=r&#038;&#038;r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme' id='gform_wrapper_123' style='display:none'><div id='gf_123' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_123' id='gform_123'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/417#gf_123' novalidate>\n        <div id='gf_progressbar_wrapper_123' class='gf_progressbar_wrapper'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>5<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_20' style='width:20%;'><span>20%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform_body gform-body'><div id='gform_page_123_1' class='gform_page' >\n                                    <div class='gform_page_fields'><div id='gform_fields_123' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_123_10\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p><img decoding=\"async\" src=\"\/wp-content\/uploads\/2022\/03\/4282-logo.jpg\" \/><\/p>\n<h3><b>Patient Information<\/b><\/h3><\/div><div id=\"field_123_2\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_2' >Birth Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_2' id='input_123_2' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_123_2_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_123_2_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_123_2' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_123_3\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_3' >Today&#039;s Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_123_3' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_123_3_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_123_3_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_123_3' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_123_4\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Patient Name<\/legend><div class='ginput_complex ginput_container has_prefix has_first_name has_middle_name has_last_name has_suffix gf_name_has_5 ginput_container_name' id='input_123_4'>\n                            <span id='input_123_4_2_container' class='name_prefix name_prefix_select' >\n                                                    <select name='input_4.2' id='input_123_4_2' aria-label='Name prefix'    aria-required='false'   >\n                          <option value=''><\/option><option value='Dr.' >Dr.<\/option><option value='Miss' >Miss<\/option><option value='Mr.' >Mr.<\/option><option value='Mrs.' >Mrs.<\/option><option value='Ms.' >Ms.<\/option><option value='Prof.' >Prof.<\/option><option value='Rev.' >Rev.<\/option>\n                      <\/select>\n                                                    <label for='input_123_4_2' >Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_123_4_3_container' class='name_first' >\n                                                    <input type='text' name='input_4.3' id='input_123_4_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_123_4_3' >First<\/label>\n                                                <\/span>\n                            <span id='input_123_4_4_container' class='name_middle' >\n                                                    <input type='text' name='input_4.4' id='input_123_4_4' value='' aria-label='Middle name'   aria-required='false'     \/>\n                                                    <label for='input_123_4_4' >Middle<\/label>\n                                                <\/span>\n                            <span id='input_123_4_6_container' class='name_last' >\n                                                    <input type='text' name='input_4.6' id='input_123_4_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_123_4_6' >Last<\/label>\n                                                <\/span>\n                            <span id='input_123_4_8_container' class='name_suffix ' >\n                                                    <input type='text' name='input_4.8' id='input_123_4_8' value='' aria-label='Name suffix'   aria-required='false'     \/>\n                                                    <label for='input_123_4_8' >Suffix<\/label>\n                                                <\/span>\n                        <\/div><\/fieldset><div id=\"field_123_5\" class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_5' >Social Security #<\/label><div class='ginput_container ginput_container_number'><input name='input_5' id='input_123_5' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_123_6\" class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_6' >Birth State<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_123_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_7\" class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_7' >Sex<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_123_7' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_8\" class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_8' >Age<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_123_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_123_12\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_123_12' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_123_12_1_container' >\n                                        <input type='text' name='input_12.1' id='input_123_12_1' value=''    aria-required='false'    \/>\n                                        <label for='input_123_12_1' id='input_123_12_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_123_12_2_container' >\n                                        <input type='text' name='input_12.2' id='input_123_12_2' value=''     aria-required='false'   \/>\n                                        <label for='input_123_12_2' id='input_123_12_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_123_12_3_container' >\n                                    <input type='text' name='input_12.3' id='input_123_12_3' value=''    aria-required='false'    \/>\n                                    <label for='input_123_12_3' id='input_123_12_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_123_12_4_container' >\n                                        <input type='text' name='input_12.4' id='input_123_12_4' value=''      aria-required='false'    \/>\n                                        <label for='input_123_12_4' id='input_123_12_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_123_12_5_container' >\n                                    <input type='text' name='input_12.5' id='input_123_12_5' value=''    aria-required='false'    \/>\n                                    <label for='input_123_12_5' id='input_123_12_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country' id='input_123_12_6_container' >\n                                        <select name='input_12.6' id='input_123_12_6'   aria-required='false'    ><option value='' selected='selected'><\/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='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/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, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, 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='Czech Republic' >Czech Republic<\/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 (Swaziland)' >Eswatini (Swaziland)<\/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 and McDonald Islands' >Heard 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='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='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/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 Korea' >North Korea<\/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='Russia' >Russia<\/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' >Saint Helena<\/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' >South Georgia<\/option><option value='South Korea' >South Korea<\/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 Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/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='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/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='Vietnam' >Vietnam<\/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                                        <label for='input_123_12_6' id='input_123_12_6_label' >Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_123_13\" class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_13' >Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_13' id='input_123_13' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_123_14\" class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_14' >Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_14' id='input_123_14' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_123_15\" class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_15' >Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_123_15' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_123_19\" class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_19' >Work EXT<\/label><div class='ginput_container ginput_container_number'><input name='input_19' id='input_123_19' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_123_16\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_16' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_16' id='input_123_16' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_123_20\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Preferred Communication<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_123_20'>\n\t\t\t<div class='gchoice gchoice_123_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Cell'  id='choice_123_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_123_20_0' id='label_123_20_0'>Cell<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_123_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Email'  id='choice_123_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_123_20_1' id='label_123_20_1'>Email<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_123_21\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_21' >Special Needs<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_123_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_22\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_22' >Primary Language<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_123_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_23\" class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_23' >Marital Status<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_123_23' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_24\" class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_24' >Maiden Name<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_123_24' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_25\" class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_25' >Mother&#039;s Maiden Name<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_123_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_26\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_26' >Gender Identity<\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_123_26' class='large gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Male' >Male<\/option><option value='Female' >Female<\/option><option value='Male-to-female transsexual' >Male-to-female transsexual<\/option><option value='Female-to-male transsexual' >Female-to-male transsexual<\/option><\/select><\/div><\/div><div id=\"field_123_27\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_27' >Sexual Orientation<\/label><div class='ginput_container ginput_container_select'><select name='input_27' id='input_123_27' class='large gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Straight' >Straight<\/option><option value='Bisexual' >Bisexual<\/option><option value='Homosexual' >Homosexual<\/option><option value='Other' >Other<\/option><option value='Don&#039;t Know' >Don&#039;t Know<\/option><\/select><\/div><\/div><div id=\"field_123_28\" class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_28' >Race<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_123_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_29\" class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_29' >Race 2<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_123_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_30\" class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_30' >Ethnicity<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_123_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_31\" class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_31' >Ethnicity 2<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_123_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_32\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_32' >Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_123_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_33\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_33' >Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_123_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_123_1' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_123\").val(\"2\");  jQuery(\"#gform_123\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_123\").val(\"2\");  jQuery(\"#gform_123\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_123_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_123_2' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_123_35\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><h3>Responsible Party Information<\/h3><\/div><div id=\"field_123_37\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_37' >Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_37' id='input_123_37' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_123_37_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_123_37_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_123_37' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_123_36\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Responsible Party&#039;s Name<\/legend><div class='ginput_complex ginput_container has_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_4 ginput_container_name' id='input_123_36'>\n                            <span id='input_123_36_2_container' class='name_prefix name_prefix_select' >\n                                                    <select name='input_36.2' id='input_123_36_2' aria-label='Name prefix'    aria-required='false'   >\n                          <option value=''><\/option><option value='Dr.' >Dr.<\/option><option value='Miss' >Miss<\/option><option value='Mr.' >Mr.<\/option><option value='Mrs.' >Mrs.<\/option><option value='Ms.' >Ms.<\/option><option value='Prof.' >Prof.<\/option><option value='Rev.' >Rev.<\/option>\n                      <\/select>\n                                                    <label for='input_123_36_2' >Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_123_36_3_container' class='name_first' >\n                                                    <input type='text' name='input_36.3' id='input_123_36_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_123_36_3' >First<\/label>\n                                                <\/span>\n                            <span id='input_123_36_4_container' class='name_middle' >\n                                                    <input type='text' name='input_36.4' id='input_123_36_4' value='' aria-label='Middle name'   aria-required='false'     \/>\n                                                    <label for='input_123_36_4' >Middle<\/label>\n                                                <\/span>\n                            <span id='input_123_36_6_container' class='name_last' >\n                                                    <input type='text' name='input_36.6' id='input_123_36_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_123_36_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_123_38\" class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_38' >Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_123_38' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_123_39\" class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_39' >Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_39' id='input_123_39' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_123_40\" class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_40' >Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_40' id='input_123_40' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_123_41\" class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_41' >Work EXT<\/label><div class='ginput_container ginput_container_number'><input name='input_41' id='input_123_41' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_123_42\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_123_42' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_123_42_1_container' >\n                                        <input type='text' name='input_42.1' id='input_123_42_1' value=''    aria-required='false'    \/>\n                                        <label for='input_123_42_1' id='input_123_42_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_123_42_2_container' >\n                                        <input type='text' name='input_42.2' id='input_123_42_2' value=''     aria-required='false'   \/>\n                                        <label for='input_123_42_2' id='input_123_42_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_123_42_3_container' >\n                                    <input type='text' name='input_42.3' id='input_123_42_3' value=''    aria-required='false'    \/>\n                                    <label for='input_123_42_3' id='input_123_42_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_123_42_4_container' >\n                                        <input type='text' name='input_42.4' id='input_123_42_4' value=''      aria-required='false'    \/>\n                                        <label for='input_123_42_4' id='input_123_42_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_123_42_5_container' >\n                                    <input type='text' name='input_42.5' id='input_123_42_5' value=''    aria-required='false'    \/>\n                                    <label for='input_123_42_5' id='input_123_42_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country' id='input_123_42_6_container' >\n                                        <select name='input_42.6' id='input_123_42_6'   aria-required='false'    ><option value='' selected='selected'><\/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='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/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, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, 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='Czech Republic' >Czech Republic<\/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 (Swaziland)' >Eswatini (Swaziland)<\/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 and McDonald Islands' >Heard 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='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='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/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 Korea' >North Korea<\/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='Russia' >Russia<\/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' >Saint Helena<\/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' >South Georgia<\/option><option value='South Korea' >South Korea<\/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 Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/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='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/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='Vietnam' >Vietnam<\/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                                        <label for='input_123_42_6' id='input_123_42_6_label' >Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_123_43\" class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_43' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_43' id='input_123_43' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_123_44\" class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_44' >Social Security #<\/label><div class='ginput_container ginput_container_number'><input name='input_44' id='input_123_44' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_123_45\" class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_45' >Gender<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_123_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_46\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_123_47\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><h3>Primary Insurance<\/h3><\/div><fieldset id=\"field_123_48\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Insured&#039;s Name<\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_123_48'>\n                            \n                            <span id='input_123_48_3_container' class='name_first' >\n                                                    <input type='text' name='input_48.3' id='input_123_48_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_123_48_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_123_48_6_container' class='name_last' >\n                                                    <input type='text' name='input_48.6' id='input_123_48_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_123_48_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_123_49\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_49' >Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_49' id='input_123_49' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_123_49_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_123_49_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_123_49' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_123_50\" class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_50' >ID Number<\/label><div class='ginput_container ginput_container_number'><input name='input_50' id='input_123_50' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_123_51\" class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_51' >Insurance Company Name<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_123_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_52\" class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_52' >Insurance Company Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_52' id='input_123_52' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_123_56\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Insurance Company Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_123_56' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_123_56_1_container' >\n                                        <input type='text' name='input_56.1' id='input_123_56_1' value=''    aria-required='false'    \/>\n                                        <label for='input_123_56_1' id='input_123_56_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_123_56_2_container' >\n                                        <input type='text' name='input_56.2' id='input_123_56_2' value=''     aria-required='false'   \/>\n                                        <label for='input_123_56_2' id='input_123_56_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_123_56_3_container' >\n                                    <input type='text' name='input_56.3' id='input_123_56_3' value=''    aria-required='false'    \/>\n                                    <label for='input_123_56_3' id='input_123_56_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_123_56_4_container' >\n                                        <input type='text' name='input_56.4' id='input_123_56_4' value=''      aria-required='false'    \/>\n                                        <label for='input_123_56_4' id='input_123_56_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_123_56_5_container' >\n                                    <input type='text' name='input_56.5' id='input_123_56_5' value=''    aria-required='false'    \/>\n                                    <label for='input_123_56_5' id='input_123_56_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country' id='input_123_56_6_container' >\n                                        <select name='input_56.6' id='input_123_56_6'   aria-required='false'    ><option value='' selected='selected'><\/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='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/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, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, 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='Czech Republic' >Czech Republic<\/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 (Swaziland)' >Eswatini (Swaziland)<\/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 and McDonald Islands' >Heard 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='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='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/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 Korea' >North Korea<\/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='Russia' >Russia<\/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' >Saint Helena<\/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' >South Georgia<\/option><option value='South Korea' >South Korea<\/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 Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/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='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/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='Vietnam' >Vietnam<\/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                                        <label for='input_123_56_6' id='input_123_56_6_label' >Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_123_54\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_54' >Group Name<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_123_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_55\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_55' >Group ID<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_123_55' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_58\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_123_59\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><h3>Secondary Insurance<\/h3><\/div><fieldset id=\"field_123_60\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Insured&#039;s Name<\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_123_60'>\n                            \n                            <span id='input_123_60_3_container' class='name_first' >\n                                                    <input type='text' name='input_60.3' id='input_123_60_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_123_60_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_123_60_6_container' class='name_last' >\n                                                    <input type='text' name='input_60.6' id='input_123_60_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_123_60_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_123_61\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_61' >Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_61' id='input_123_61' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_123_61_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_123_61_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_123_61' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_123_62\" class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_62' >ID Number<\/label><div class='ginput_container ginput_container_number'><input name='input_62' id='input_123_62' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_123_63\" class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_63' >Insurance Company Name<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_123_63' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_64\" class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_64' >Insurance Company Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_64' id='input_123_64' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_123_65\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Insurance CompanyAddress<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_123_65' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_123_65_1_container' >\n                                        <input type='text' name='input_65.1' id='input_123_65_1' value=''    aria-required='false'    \/>\n                                        <label for='input_123_65_1' id='input_123_65_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_123_65_2_container' >\n                                        <input type='text' name='input_65.2' id='input_123_65_2' value=''     aria-required='false'   \/>\n                                        <label for='input_123_65_2' id='input_123_65_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_123_65_3_container' >\n                                    <input type='text' name='input_65.3' id='input_123_65_3' value=''    aria-required='false'    \/>\n                                    <label for='input_123_65_3' id='input_123_65_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_123_65_4_container' >\n                                        <input type='text' name='input_65.4' id='input_123_65_4' value=''      aria-required='false'    \/>\n                                        <label for='input_123_65_4' id='input_123_65_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_123_65_5_container' >\n                                    <input type='text' name='input_65.5' id='input_123_65_5' value=''    aria-required='false'    \/>\n                                    <label for='input_123_65_5' id='input_123_65_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country' id='input_123_65_6_container' >\n                                        <select name='input_65.6' id='input_123_65_6'   aria-required='false'    ><option value='' selected='selected'><\/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='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/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, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, 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='Czech Republic' >Czech Republic<\/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 (Swaziland)' >Eswatini (Swaziland)<\/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 and McDonald Islands' >Heard 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='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='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/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 Korea' >North Korea<\/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='Russia' >Russia<\/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' >Saint Helena<\/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' >South Georgia<\/option><option value='South Korea' >South Korea<\/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 Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/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='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/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='Vietnam' >Vietnam<\/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                                        <label for='input_123_65_6' id='input_123_65_6_label' >Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_123_66\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_66' >Group Name<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_123_66' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_67\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_67' >Group Number<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_123_67' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_123_34' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_123\").val(\"1\");  jQuery(\"#gform_123\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_123\").val(\"1\");  jQuery(\"#gform_123\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_123_34' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_123\").val(\"3\");  jQuery(\"#gform_123\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_123\").val(\"3\");  jQuery(\"#gform_123\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_123_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_123_3' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_123_69\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_69' >Monthly Income $<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_123_69' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_123_70\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Are you currently on food stamps?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_123_70'>\n\t\t\t<div class='gchoice gchoice_123_70_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Yes'  id='choice_123_70_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_123_70_0' id='label_123_70_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_123_70_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='No'  id='choice_123_70_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_123_70_1' id='label_123_70_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_123_71\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Referrals - Shelters and Organizations only<\/legend><div class='ginput_container ginput_container_list ginput_list'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header\"><div class=\"gfield_header_item\">Firm\/Organization\/Name<\/div><div class=\"gfield_header_item\">Phone<\/div><div class=\"gfield_header_item\">Address<\/div><div class=\"gfield_header_item\">Contact Person<\/div><div class=\"gfield_header_item\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group'><div class='gfield_list_group_item gfield_list_cell gfield_list_71_cell1' data-label='Firm\/Organization\/Name'><input aria-invalid='false'   aria-label='Firm\/Organization\/Name, Row 1' data-aria-label-template='Firm\/Organization\/Name, Row {0}' type='text' name='input_71[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_71_cell2' data-label='Phone'><input aria-invalid='false'   aria-label='Phone, Row 1' data-aria-label-template='Phone, Row {0}' type='text' name='input_71[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_71_cell3' data-label='Address'><input aria-invalid='false'   aria-label='Address, Row 1' data-aria-label-template='Address, Row {0}' type='text' name='input_71[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_71_cell4' data-label='Contact Person'><input aria-invalid='false'   aria-label='Contact Person, Row 1' data-aria-label-template='Contact Person, Row {0}' type='text' name='input_71[]' value=''   \/><\/div><div class='gfield_list_icons'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_123_68' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_123\").val(\"2\");  jQuery(\"#gform_123\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_123\").val(\"2\");  jQuery(\"#gform_123\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_123_68' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_123\").val(\"4\");  jQuery(\"#gform_123\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_123\").val(\"4\");  jQuery(\"#gform_123\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_123_4' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_123_4' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_123_72\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><h3>Patient History<\/h3><\/div><fieldset id=\"field_123_74\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Name<\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_123_74'>\n                            \n                            <span id='input_123_74_3_container' class='name_first' >\n                                                    <input type='text' name='input_74.3' id='input_123_74_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_123_74_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_123_74_6_container' class='name_last' >\n                                                    <input type='text' name='input_74.6' id='input_123_74_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_123_74_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_123_75\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_75' >Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_75' id='input_123_75' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_123_75_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_123_75_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_123_75' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_123_76\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_76' >Reason for today&#039;s clinic visit:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_76' id='input_123_76' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_123_77\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_77' >Please list any concerns you have about your eyes or vision:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_77' id='input_123_77' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_123_78\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_78' >Last Eye Exam<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_78' id='input_123_78' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_123_78_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_123_78_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_123_78' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_123_79\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_79' >Dr. or Location<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_123_79' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_80\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_80' >Last Physical Exam<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_80' id='input_123_80' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_123_80_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_123_80_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_123_80' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_123_81\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_81' >Dr. or Location<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_123_81' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_82\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><h3>Current Medications<\/h3><\/div><fieldset id=\"field_123_83\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Please list any medications that you are now taking. Include non-prescription medications &amp; vitamins or supplements:<\/legend><div class='ginput_container ginput_container_list ginput_list'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header\"><div class=\"gfield_header_item\">Name of Drug<\/div><div class=\"gfield_header_item\">Dose (include strength &amp; number of pills per day)<\/div><div class=\"gfield_header_item\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group'><div class='gfield_list_group_item gfield_list_cell gfield_list_83_cell1' data-label='Name of Drug'><input aria-invalid='false'   aria-label='Name of Drug, Row 1' data-aria-label-template='Name of Drug, Row {0}' type='text' name='input_83[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_83_cell2' data-label='Dose (include strength &amp; number of pills per day)'><input aria-invalid='false'   aria-label='Dose (include strength &amp; number of pills per day), Row 1' data-aria-label-template='Dose (include strength &amp; number of pills per day), Row {0}' type='text' name='input_83[]' value=''   \/><\/div><div class='gfield_list_icons'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_123_84\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Drug Allergies<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_123_84'>\n\t\t\t<div class='gchoice gchoice_123_84_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Yes'  id='choice_123_84_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_123_84_0' id='label_123_84_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_123_84_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='No'  id='choice_123_84_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_123_84_1' id='label_123_84_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_123_85\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_85' >To What?<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_123_85' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_123_86' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_123\").val(\"3\");  jQuery(\"#gform_123\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_123\").val(\"3\");  jQuery(\"#gform_123\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_123_86' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_123\").val(\"5\");  jQuery(\"#gform_123\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_123\").val(\"5\");  jQuery(\"#gform_123\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_123_5' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_123_5' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_123_87\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><h3>Past Medical History<\/h3><\/div><fieldset id=\"field_123_88\" class=\"gfield gfield--width-half gf_list_2col field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Do you now or have you ever had:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_123_88'><div class='gchoice gchoice_123_88_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.1' type='checkbox'  value='Diabetes'  id='choice_123_88_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_88_1' id='label_123_88_1'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_88_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.2' type='checkbox'  value='High blood pressure'  id='choice_123_88_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_88_2' id='label_123_88_2'>High blood pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_88_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.3' type='checkbox'  value='High cholesterol'  id='choice_123_88_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_88_3' id='label_123_88_3'>High cholesterol<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_88_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.4' type='checkbox'  value='Stroke'  id='choice_123_88_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_88_4' id='label_123_88_4'>Stroke<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_88_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.5' type='checkbox'  value='Heart problems'  id='choice_123_88_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_88_5' id='label_123_88_5'>Heart problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_88_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.6' type='checkbox'  value='Cancer'  id='choice_123_88_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_88_6' id='label_123_88_6'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_88_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.7' type='checkbox'  value='Arthritis'  id='choice_123_88_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_88_7' id='label_123_88_7'>Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_88_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.8' type='checkbox'  value='Thyroid problems'  id='choice_123_88_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_88_8' id='label_123_88_8'>Thyroid problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_88_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.9' type='checkbox'  value='Liver Problems'  id='choice_123_88_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_88_9' id='label_123_88_9'>Liver Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_88_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.11' type='checkbox'  value='Kidney Problems'  id='choice_123_88_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_88_11' id='label_123_88_11'>Kidney Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_88_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.12' type='checkbox'  value='Cataracts'  id='choice_123_88_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_88_12' id='label_123_88_12'>Cataracts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_88_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.13' type='checkbox'  value='Glaucoma'  id='choice_123_88_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_88_13' id='label_123_88_13'>Glaucoma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_88_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.14' type='checkbox'  value='Macular Degeneration'  id='choice_123_88_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_88_14' id='label_123_88_14'>Macular Degeneration<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_88_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.15' type='checkbox'  value='Crossed Eyes\/Strabismus'  id='choice_123_88_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_88_15' id='label_123_88_15'>Crossed Eyes\/Strabismus<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_88_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.16' type='checkbox'  value='Contact Lens Wear'  id='choice_123_88_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_88_16' id='label_123_88_16'>Contact Lens Wear<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_88_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.17' type='checkbox'  value='Eye Sx'  id='choice_123_88_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_88_17' id='label_123_88_17'>Eye Sx<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_88_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.18' type='checkbox'  value='Eye Injury'  id='choice_123_88_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_88_18' id='label_123_88_18'>Eye Injury<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_123_89\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Family Ocular Medical Hx<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_123_89'><div class='gchoice gchoice_123_89_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_89.1' type='checkbox'  value='Diabetes'  id='choice_123_89_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_89_1' id='label_123_89_1'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_89_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_89.2' type='checkbox'  value='Hypertension'  id='choice_123_89_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_89_2' id='label_123_89_2'>Hypertension<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_89_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_89.3' type='checkbox'  value='Stroke'  id='choice_123_89_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_89_3' id='label_123_89_3'>Stroke<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_89_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_89.4' type='checkbox'  value='Heart'  id='choice_123_89_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_89_4' id='label_123_89_4'>Heart<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_89_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_89.5' type='checkbox'  value='Cataracts'  id='choice_123_89_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_89_5' id='label_123_89_5'>Cataracts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_89_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_89.6' type='checkbox'  value='Glaucoma'  id='choice_123_89_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_89_6' id='label_123_89_6'>Glaucoma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_89_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_89.7' type='checkbox'  value='Macular Degeneration'  id='choice_123_89_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_89_7' id='label_123_89_7'>Macular Degeneration<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_123_89_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_89.8' type='checkbox'  value='Strabismus'  id='choice_123_89_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_123_89_8' id='label_123_89_8'>Strabismus<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_123_90\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_90' >Cancer Type<\/label><div class='ginput_container ginput_container_text'><input name='input_90' id='input_123_90' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_91\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_91' >Any other patient\/familymedical or ocular conditions (please list):<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_91' id='input_123_91' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_123_92\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Do you drink alcohol?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_123_92'>\n\t\t\t<div class='gchoice gchoice_123_92_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Yes'  id='choice_123_92_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_123_92_0' id='label_123_92_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_123_92_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='No'  id='choice_123_92_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_123_92_1' id='label_123_92_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_123_94\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Do you use tobacco?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_123_94'>\n\t\t\t<div class='gchoice gchoice_123_94_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='Yes'  id='choice_123_94_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_123_94_0' id='label_123_94_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_123_94_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='No'  id='choice_123_94_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_123_94_1' id='label_123_94_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_123_93\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_93' >Servings per week<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_123_93' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_123_95\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_123_95' >If yes, how much?<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_123_95' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_123_96\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Do your hobbies or work put you at risk of an eye injury?<\/legend><div 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