{"id":10315,"date":"2019-04-16T13:23:26","date_gmt":"2019-04-16T18:23:26","guid":{"rendered":"https:\/\/www.totalwellnesshealth.com\/?page_id=10315"},"modified":"2024-05-22T09:20:49","modified_gmt":"2024-05-22T14:20:49","slug":"order-on-site-flu-shots","status":"publish","type":"page","link":"https:\/\/www.totalwellnesshealth.com\/order-on-site-flu-shots\/","title":{"rendered":"Order Form On-Site Flu Shots"},"content":{"rendered":"\n\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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2024-2025<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_866'  action='\/wp-json\/wp\/v2\/pages\/10315' data-formid='866' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_866' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_866_47\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Complete the form below to order your flu shot event. <\/li><li id=\"field_866_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_866_21'>Company Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_866_21' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_866_1\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address of Flu Shot Event<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_866_1' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_866_1_1_container' >\n                                        <input type='text' name='input_1.1' id='input_866_1_1' value=''    aria-required='true'    \/>\n                                        <label for='input_866_1_1' id='input_866_1_1_label' class='gform-field-label gform-field-label--type-sub '>Address Line 1<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_866_1_2_container' >\n                                        <input type='text' name='input_1.2' id='input_866_1_2' value=''     aria-required='false'   \/>\n                                        <label for='input_866_1_2' id='input_866_1_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_866_1_3_container' >\n                                    <input type='text' name='input_1.3' id='input_866_1_3' value=''    aria-required='true'    \/>\n                                    <label for='input_866_1_3' id='input_866_1_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_866_1_4_container' >\n                                        <select name='input_1.4' id='input_866_1_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_866_1_4' id='input_866_1_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_866_1_5_container' >\n                                    <input type='text' name='input_1.5' id='input_866_1_5' value=''    aria-required='true'    \/>\n                                    <label for='input_866_1_5' id='input_866_1_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_1.6' id='input_866_1_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_866_32\" class=\"gfield gfield--type-product gfield--input-type-hiddenproduct gform_hidden gfield_price gfield_price_866_32 gfield_product_866_32 gfield_hidden_product field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_866_32_1'>Flu Shot<\/label><div class='ginput_container ginput_container_product_price_hidden'><input type='hidden' name='input_32.1' value='Flu Shot' class='gform_hidden' \/><input name='input_32.2' id='ginput_base_price_866_32' type='hidden' value='$35.00' class='gform_hidden ginput_amount' \/><\/div><\/li><li id=\"field_866_16\" class=\"gfield gfield--type-quantity gfield--input-type-select gfield_price gfield_price_866_32 gfield_quantity gfield_quantity_866_32 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_866_16'>Quantity of Flu Shots &#8211; $35.00 per shot<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_866_16' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='20' >20<\/option><option value='25' >25<\/option><option value='30' >30<\/option><option value='35' >35<\/option><option value='40' >40<\/option><\/select><\/div><\/li><li id=\"field_866_13\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield_price gfield_price_866_13 gfield_product_866_13 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_866_13_1'>Small Site Fee<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_13.1' value='Small Site Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_866_13' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_13.2' id='ginput_base_price_866_13' value='$250.00' aria-label='Small Site Fee Price' aria-describedby=\"gfield_description_866_13\" \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_13.3' value='1' class='ginput_quantity_866_13 gform_hidden' \/>\n\t\t\t\t<\/div><div class='gfield_description' id='gfield_description_866_13'>Since you are ordering less than 40 shots, there is an additional $250 small site fee. <\/div><\/li><li id=\"field_866_6\" class=\"gfield gfield--type-total gfield--input-type-total gfield_price gfield_price_866_ gfield_total gfield_total_866_ field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  aria-atomic=\"true\" aria-live=\"polite\" ><label class='gfield_label gform-field-label' for='input_866_6'>Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<span class='ginput_total ginput_total_866'>$0.00<\/span>\n\t\t\t\t\t\t\t<input type='hidden' name='input_6' id='input_866_6' class='gform_hidden'\/>\n\t\t\t\t\t\t<\/div><\/li><li id=\"field_866_73\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_866_73'>Number of Flu Shots Ordered<\/label><div class='ginput_container ginput_container_select'><select name='input_73' id='input_866_73' class='small gfield_select'     aria-invalid=\"false\" ><option value='20' selected='selected'>20<\/option><\/select><\/div><\/li><li id=\"field_866_74\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_866_74'>Number of Flu Shots Ordered<\/label><div class='ginput_container ginput_container_select'><select name='input_74' id='input_866_74' class='small gfield_select'     aria-invalid=\"false\" ><option value='25' selected='selected'>25<\/option><\/select><\/div><\/li><li id=\"field_866_75\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_866_75'>Number of Flu Shots Ordered<\/label><div class='ginput_container ginput_container_select'><select name='input_75' id='input_866_75' class='small gfield_select'     aria-invalid=\"false\" ><option value='30' selected='selected'>30<\/option><\/select><\/div><\/li><li id=\"field_866_76\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_866_76'>Number of Flu Shots Ordered<\/label><div class='ginput_container ginput_container_select'><select name='input_76' id='input_866_76' class='small gfield_select'     aria-invalid=\"false\" ><option value='35' selected='selected'>35<\/option><\/select><\/div><\/li><li id=\"field_866_77\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_866_77'>Number of Flu Shots Ordered<\/label><div class='ginput_container ginput_container_select'><select name='input_77' id='input_866_77' class='small gfield_select'     aria-invalid=\"false\" ><option value='40' selected='selected'>40<\/option><\/select><\/div><\/li><li id=\"field_866_34\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><script type=\"text\/javascript\">\n\n gform.addFilter( 'gform_datepicker_options_pre_init', function( optionsObj, formId, fieldId ) {\n\n if ( formId == 866 && fieldId == 35 ) {\n optionsObj.minDate = '+30 D';\n optionsObj.maxDate = '+300 D';\n \n }\n return optionsObj;\n } );\n\n<\/script><\/li><li id=\"field_866_35\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_866_35'>Requested Event Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_866_35'>Please select your preferred date for flu shot event. We require at least 30 days notice. Please note that we start on-site flu events after September 1.<\/div><div class='ginput_container ginput_container_date'>\n                            <input name='input_35' id='input_866_35' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_866_35_date_format gfield_description_866_35\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_866_35_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_866_35' class='gform_hidden' value='https:\/\/www.totalwellnesshealth.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_866_36\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_866_36'>Requested Event Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_866_36'>Your order includes two hours of event time.<\/div><div class='ginput_container ginput_container_select'><select name='input_36' id='input_866_36' class='small gfield_select'  aria-describedby=\"gfield_description_866_36\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='7:00am - 9:00am' >7:00am &#8211; 9:00am<\/option><option value='7:30am - 9:30am' >7:30am &#8211; 9:30am<\/option><option value='8:00am - 10:00am' >8:00am &#8211; 10:00am<\/option><option value='8:30am - 10:30am' >8:30am &#8211; 10:30am<\/option><option value='9:00am - 11:00am' >9:00am &#8211; 11:00am<\/option><option value='9:30am - 11:30am' >9:30am &#8211; 11:30am<\/option><option value='10:00am - 12:00pm' >10:00am &#8211; 12:00pm<\/option><option value='10:30am - 12:30pm' >10:30am &#8211; 12:30pm<\/option><option value='11:00am - 1:00pm' >11:00am &#8211; 1:00pm<\/option><option value='11:30am - 1:30pm' >11:30am &#8211; 1:30pm<\/option><option value='12:00pm - 2:00pm' >12:00pm &#8211; 2:00pm<\/option><option value='12:30pm - 2:30pm' >12:30pm &#8211; 2:30pm<\/option><option value='1:00pm - 3:00pm' >1:00pm &#8211; 3:00pm<\/option><option value='1:30pm - 3:30pm' >1:30pm &#8211; 3:30pm<\/option><option value='2:00pm - 4:00pm' >2:00pm &#8211; 4:00pm<\/option><option value='2:30pm - 4:30pm' >2:30pm &#8211; 4:30pm<\/option><option value='3:00pm - 5:00pm' >3:00pm &#8211; 5:00pm<\/option><option value='3:30pm - 5:30pm' >3:30pm &#8211; 5:30pm<\/option><option value='4:00pm - 6:00pm' >4:00pm &#8211; 6:00pm<\/option><option value='4:30pm - 6:30pm' >4:30pm &#8211; 6:30pm<\/option><option value='5:00pm - 7:00pm' >5:00pm &#8211; 7:00pm<\/option><\/select><\/div><\/li><li id=\"field_866_37\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_866_37'>Requested Event Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_866_37'>Your order includes two and a half hours of event time.<\/div><div class='ginput_container ginput_container_select'><select name='input_37' id='input_866_37' class='small gfield_select'  aria-describedby=\"gfield_description_866_37\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='7:00am - 9:30am' >7:00am &#8211; 9:30am<\/option><option value='7:30am - 10:00am' >7:30am &#8211; 10:00am<\/option><option value='8:00am - 10:30am' >8:00am &#8211; 10:30am<\/option><option value='8:30am - 11:00am' >8:30am &#8211; 11:00am<\/option><option value='9:00am - 11:30am' >9:00am &#8211; 11:30am<\/option><option value='9:30am - 12:00pm' >9:30am &#8211; 12:00pm<\/option><option value='10:00am - 12:30pm' >10:00am &#8211; 12:30pm<\/option><option value='10:30am - 1:00pm' >10:30am &#8211; 1:00pm<\/option><option value='11:00am - 1:30pm' >11:00am &#8211; 1:30pm<\/option><option value='11:30am - 2:00pm' >11:30am &#8211; 2:00pm<\/option><option value='12:00pm - 2:30pm' >12:00pm &#8211; 2:30pm<\/option><option value='12:30pm - 3:00pm' >12:30pm &#8211; 3:00pm<\/option><option value='1:00pm - 3:30pm' >1:00pm &#8211; 3:30pm<\/option><option value='1:30pm - 4:00pm' >1:30pm &#8211; 4:00pm<\/option><option value='2:00pm - 4:30pm' >2:00pm &#8211; 4:30pm<\/option><option value='2:30pm - 5:00pm' >2:30pm &#8211; 5:00pm<\/option><option value='3:00pm - 5:30pm' >3:00pm &#8211; 5:30pm<\/option><option value='3:30pm - 6:00pm' >3:30pm &#8211; 6:00pm<\/option><option value='4:00pm - 6:30pm' >4:00pm &#8211; 6:30pm<\/option><option value='4:30pm - 7:00pm' >4:30pm &#8211; 7:00pm<\/option><\/select><\/div><\/li><li id=\"field_866_40\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_866_40'>Requested Event Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_866_40'>Your order includes three hours of event time.<\/div><div class='ginput_container ginput_container_select'><select name='input_40' id='input_866_40' class='small gfield_select'  aria-describedby=\"gfield_description_866_40\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='7:00am - 10:00am' >7:00am &#8211; 10:00am<\/option><option value='7:30am - 10:30am' >7:30am &#8211; 10:30am<\/option><option value='8:00am - 11:00am' >8:00am &#8211; 11:00am<\/option><option value='8:30am - 11:30am' >8:30am &#8211; 11:30am<\/option><option value='9:00am - 12:00pm' >9:00am &#8211; 12:00pm<\/option><option value='9:30am - 12:30pm' >9:30am &#8211; 12:30pm<\/option><option value='10:00am - 1:00pm' >10:00am &#8211; 1:00pm<\/option><option value='10:30am - 1:30pm' >10:30am &#8211; 1:30pm<\/option><option value='11:00am - 2:00pm' >11:00am &#8211; 2:00pm<\/option><option value='11:30am - 2:30pm' >11:30am &#8211; 2:30pm<\/option><option value='12:00pm - 3:00pm' >12:00pm &#8211; 3:00pm<\/option><option value='12:30pm - 3:30pm' >12:30pm &#8211; 3:30pm<\/option><option value='1:00pm - 4:00pm' >1:00pm &#8211; 4:00pm<\/option><option value='1:30pm - 4:30pm' >1:30pm &#8211; 4:30pm<\/option><option value='2:00pm - 5:00pm' >2:00pm &#8211; 5:00pm<\/option><option value='2:30pm - 5:30pm' >2:30pm &#8211; 5:30pm<\/option><option value='3:00pm - 6:00pm' >3:00pm &#8211; 6:00pm<\/option><option value='3:30pm - 6:30pm' >3:30pm &#8211; 6:30pm<\/option><option value='4:00pm - 7:00pm' >4:00pm &#8211; 7:00pm<\/option><\/select><\/div><\/li><li id=\"field_866_38\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_866_38'>Requested Event Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_866_38'>Your order includes three and a half hours of event time.<\/div><div class='ginput_container ginput_container_select'><select name='input_38' id='input_866_38' class='small gfield_select'  aria-describedby=\"gfield_description_866_38\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='7:00am - 10:30am' >7:00am &#8211; 10:30am<\/option><option value='7:30am - 11:00am' >7:30am &#8211; 11:00am<\/option><option value='8:00am - 11:30am' >8:00am &#8211; 11:30am<\/option><option value='8:30am - 12:00pm' >8:30am &#8211; 12:00pm<\/option><option value='9:00am - 12:30pm' >9:00am &#8211; 12:30pm<\/option><option value='9:30am - 1:00pm' >9:30am &#8211; 1:00pm<\/option><option value='10:00am - 1:30pm' >10:00am &#8211; 1:30pm<\/option><option value='10:30am - 2:00pm' >10:30am &#8211; 2:00pm<\/option><option value='11:00am - 2:30pm' >11:00am &#8211; 2:30pm<\/option><option value='11:30am - 3:00pm' >11:30am &#8211; 3:00pm<\/option><option value='12:00pm - 3:30pm' >12:00pm &#8211; 3:30pm<\/option><option value='12:30pm - 4:00pm' >12:30pm &#8211; 4:00pm<\/option><option value='1:00pm - 4:30pm' >1:00pm &#8211; 4:30pm<\/option><option value='1:30pm - 5:00pm' >1:30pm &#8211; 5:00pm<\/option><option value='2:00pm - 5:30pm' >2:00pm &#8211; 5:30pm<\/option><option value='2:30pm - 6:00pm' >2:30pm &#8211; 6:00pm<\/option><option value='3:00pm - 6:30pm' >3:00pm &#8211; 6:30pm<\/option><option value='3:30pm - 7:00pm' >3:30pm &#8211; 7:00pm<\/option><\/select><\/div><\/li><li id=\"field_866_39\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_866_39'>Requested Event Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_866_39'>Your order includes four hours of event time.<\/div><div class='ginput_container ginput_container_select'><select name='input_39' id='input_866_39' class='small gfield_select'  aria-describedby=\"gfield_description_866_39\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='7:00am - 11:00am' >7:00am &#8211; 11:00am<\/option><option value='7:30am - 11:30am' >7:30am &#8211; 11:30am<\/option><option value='8:00am - 12:00pm' >8:00am &#8211; 12:00pm<\/option><option value='8:30am - 12:30pm' >8:30am &#8211; 12:30pm<\/option><option value='9:00am - 1:00pm' >9:00am &#8211; 1:00pm<\/option><option value='9:30am - 1:30pm' >9:30am &#8211; 1:30pm<\/option><option value='10:00am - 2:00pm' >10:00am &#8211; 2:00pm<\/option><option value='10:30am - 2:30pm' >10:30am &#8211; 2:30pm<\/option><option value='11:00am - 3:00pm' >11:00am &#8211; 3:00pm<\/option><option value='11:30am - 3:30pm' >11:30am &#8211; 3:30pm<\/option><option value='12:00pm - 4:00pm' >12:00pm &#8211; 4:00pm<\/option><option value='12:30pm - 4:30pm' >12:30pm &#8211; 4:30pm<\/option><option value='1:00pm - 5:00pm' >1:00pm &#8211; 5:00pm<\/option><option value='1:30pm - 5:30pm' >1:30pm &#8211; 5:30pm<\/option><option value='2:00pm - 6:00pm' >2:00pm &#8211; 6:00pm<\/option><option value='2:30pm - 6:30pm' >2:30pm &#8211; 6:30pm<\/option><option value='3:00pm - 7:00pm' >3:00pm &#8211; 7:00pm<\/option><\/select><\/div><\/li><li id=\"field_866_41\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_866_41'>Requested Event Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_866_41'>Your order includes five hours of event time.<\/div><div class='ginput_container ginput_container_select'><select name='input_41' id='input_866_41' class='small gfield_select'  aria-describedby=\"gfield_description_866_41\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='7:00am - 12:00pm' >7:00am &#8211; 12:00pm<\/option><option value='7:30am - 12:30pm' >7:30am &#8211; 12:30pm<\/option><option value='8:00am - 1:00pm' >8:00am &#8211; 1:00pm<\/option><option value='8:30am - 1:30pm' >8:30am &#8211; 1:30pm<\/option><option value='9:00am - 2:00pm' >9:00am &#8211; 2:00pm<\/option><option value='9:30am - 2:30pm' >9:30am &#8211; 2:30pm<\/option><option value='10:00am - 3:00pm' >10:00am &#8211; 3:00pm<\/option><option value='10:30am - 3:30pm' >10:30am &#8211; 3:30pm<\/option><option value='11:00am - 4:00pm' >11:00am &#8211; 4:00pm<\/option><option value='11:30am - 4:30pm' >11:30am &#8211; 4:30pm<\/option><option value='12:00pm - 5:00pm' >12:00pm &#8211; 5:00pm<\/option><option value='12:30pm - 5:30pm' >12:30pm &#8211; 5:30pm<\/option><option value='1:00pm - 6:00pm' >1:00pm &#8211; 6:00pm<\/option><option value='1:30pm - 6:30pm' >1:30pm &#8211; 6:30pm<\/option><option value='2:00pm - 7:00pm' >2:00pm &#8211; 7:00pm<\/option><\/select><\/div><\/li><li id=\"field_866_42\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_866_42'>Requested Event Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_866_42'>Your order includes four and a half hours of event time.<\/div><div class='ginput_container ginput_container_select'><select name='input_42' id='input_866_42' class='small gfield_select'  aria-describedby=\"gfield_description_866_42\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='7:00am - 11:30am' >7:00am &#8211; 11:30am<\/option><option value='7:30am - 12:00pm' >7:30am &#8211; 12:00pm<\/option><option value='8:00am - 12:30pm' >8:00am &#8211; 12:30pm<\/option><option value='8:30am - 1:00pm' >8:30am &#8211; 1:00pm<\/option><option value='9:00am - 1:30pm' >9:00am &#8211; 1:30pm<\/option><option value='9:30am - 2:00pm' >9:30am &#8211; 2:00pm<\/option><option value='10:00am - 2:30pm' >10:00am &#8211; 2:30pm<\/option><option value='10:30am - 3:00pm' >10:30am &#8211; 3:00pm<\/option><option value='11:00am - 3:30pm' >11:00am &#8211; 3:30pm<\/option><option value='11:30am - 4:00pm' >11:30am &#8211; 4:00pm<\/option><option value='12:00pm - 4:30pm' >12:00pm &#8211; 4:30pm<\/option><option value='12:30pm - 5:00pm' >12:30pm &#8211; 5:00pm<\/option><option value='1:00pm - 5:30pm' >1:00pm &#8211; 5:30pm<\/option><option value='1:30pm - 6:00pm' >1:30pm &#8211; 6:00pm<\/option><option value='2:00pm - 6:30pm' >2:00pm &#8211; 6:30pm<\/option><option value='2:30pm - 7:00pm' >2:30pm &#8211; 7:00pm<\/option><\/select><\/div><\/li><li id=\"field_866_61\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_866_61'>Would you like to use our participant online appointment scheduling tool?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_61' id='input_866_61' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_866_62\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_866_62'>Please include location security, parking, and driving instructions.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_62' id='input_866_62' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_866_45\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Contact Information<\/h2><\/li><li id=\"field_866_51\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_866_51'>Are you the overall company contact and the day of event site contact?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_51' id='input_866_51' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_866_2\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_866_2'>\n                            \n                            <span id='input_866_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_866_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_866_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_866_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_866_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_866_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_866_12\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_866_12'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_12' id='input_866_12' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_866_22\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_866_22'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_22' id='input_866_22' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_866_52\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Site Contact Information<\/h2><\/li><li id=\"field_866_25\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Site Contact Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_866_25'>\n                            \n                            <span id='input_866_25_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_25.3' id='input_866_25_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_866_25_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_866_25_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_25.6' id='input_866_25_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_866_25_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_866_26\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_866_26'>Site Contact Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_26' id='input_866_26' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_866_27\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_866_27'>Site Contact Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_27' id='input_866_27' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_866_46\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Important Points<\/h2><\/li><li id=\"field_866_56\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><html>\n<head>\n\t<title><\/title>\n<\/head>\n<body>\n<p><strong>Please check the box next to each statement indicating that you understand and agree to the policy.<\/strong><\/p>\n<\/body>\n<\/html><\/li><li id=\"field_866_66\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Charges for Additional Shots Administered &amp; Extra Nurse Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_866_66'><li class='gchoice gchoice_866_66_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.1' type='checkbox'  value='The credit card provided will be charged for the total event cost. If more shots are administered than the number ordered, TotalWellness will invoice the company for the additional shots at $35.00 per shot. If the nurse is requested to stay past the event end time, TotalWellness will charge for the additional time at $85 per hour, per nurse.'  id='choice_866_66_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_866_66_1' id='label_866_66_1' class='gform-field-label gform-field-label--type-inline'>The credit card provided will be charged for the total event cost. If more shots are administered than the number ordered, TotalWellness will invoice the company for the additional shots at $35.00 per shot. If the nurse is requested to stay past the event end time, TotalWellness will charge for the additional time at $85 per hour, per nurse.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_866_67\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Change Fees<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_866_67'><li class='gchoice gchoice_866_67_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.1' type='checkbox'  value='You may increase the number of shots ordered, adjust the event time or change the event location within the same metro area within 14 days of the event for no fee, 11-13 days prior to the event for a $75 fee, and 10 or fewer days prior to the event for a $150 fee. Decreases to event order numbers are not allowed. Event dates cannot be changed once confirmed without a fee.'  id='choice_866_67_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_866_67_1' id='label_866_67_1' class='gform-field-label gform-field-label--type-inline'>You may increase the number of shots ordered, adjust the event time or change the event location within the same metro area within 14 days of the event for no fee, 11-13 days prior to the event for a $75 fee, and 10 or fewer days prior to the event for a $150 fee. Decreases to event order numbers are not allowed. Event dates cannot be changed once confirmed without a fee.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_866_68\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Cancellation and Rescheduling Fees<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_866_68'><li class='gchoice gchoice_866_68_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.1' type='checkbox'  value='Once confirmed, cancelling or rescheduling your event will incur a minimum $75 fee. Cancellations or reschedules requested 14 \u2013 30 days prior to the event days will incur a $150 fee, requests submitted 8 \u2013 13 days prior to the event will incur a $300 fee and requests submitted 7 or fewer days prior to the event will incur a $500 fee.'  id='choice_866_68_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_866_68_1' id='label_866_68_1' class='gform-field-label gform-field-label--type-inline'>Once confirmed, cancelling or rescheduling your event will incur a minimum $75 fee. Cancellations or reschedules requested 14 \u2013 30 days prior to the event days will incur a $150 fee, requests submitted 8 \u2013 13 days prior to the event will incur a $300 fee and requests submitted 7 or fewer days prior to the event will incur a $500 fee.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_866_69\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Age Policy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_866_69'><li class='gchoice gchoice_866_69_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.1' type='checkbox'  value='TotalWellness does not vaccinate children. All participants must be a legal adult in the state where the shots are being administered.'  id='choice_866_69_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_866_69_1' id='label_866_69_1' class='gform-field-label gform-field-label--type-inline'>TotalWellness does not vaccinate children. All participants must be a legal adult in the state where the shots are being administered.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_866_64\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Payment<\/h2><\/li><li id=\"field_866_78\" class=\"gfield gfield--type-stripe_creditcard gfield--input-type-stripe_creditcard gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--type-stripe_creditcard-payment-element\"  ><label class='gfield_label gfield_label_before_complex gform-field-label' for='input_866_78_1'>Credit Card<\/label><div class='ginput_complex ginput_container ginput_container_creditcard ginput_stripe_creditcard gform-grid-row' id='input_866_78'><div class='ginput_full gform-grid-col' id='input_866_78_1_container' data-payment-element='true'><div id='input_866_78_1' class='StripeElement--payment-element'><\/div><\/div><!-- .ginput_full --><\/div><!-- .ginput_container -->\r\n\t\t\t<style type=\"text\/css\">\r\n\t\t\t\t:root {\r\n  \t\t\t\t\t--link-login-string: \"Link login\"\r\n\t\t\t\t}\r\n\t\t\t<\/style><\/li><li id=\"field_866_65\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Agreement Terms<\/h2><\/li><li id=\"field_866_14\" class=\"gfield gfield--type-tos gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Terms of Service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_866_14'>You must scroll through the entire terms of service before agreeing to the terms.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_866_14'><li class='gchoice gchoice_866_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='I agree to the Terms of Service'  id='choice_866_14_1'   aria-describedby=\"gfield_description_866_14\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_866_14_1' id='label_866_14_1' class='gform-field-label gform-field-label--type-inline'>I agree to the Terms of Service<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_866_3\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below 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for='input_866_79'>TotalWellness Account Executive<\/label><div class='ginput_container ginput_container_select'><select name='input_79' id='input_866_79' class='large gfield_select'     aria-invalid=\"false\" ><option value='Liz Howard | lhoward@totalwellnesshealth.com | 402.964.0542 x112' selected='selected'>Liz Howard | lhoward@totalwellnesshealth.com | 402.964.0542 x112<\/option><option value='' ><\/option><option value='' ><\/option><\/select><\/div><\/li><li id=\"field_866_80\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_866_80'>TotalWellness Account Executive<\/label><div class='ginput_container ginput_container_select'><select name='input_80' id='input_866_80' class='large gfield_select'     aria-invalid=\"false\" ><option value='Aubrey Goff | agoff@totalwellnesshealth.com | 402.964.0542 x117' selected='selected'>Aubrey Goff | agoff@totalwellnesshealth.com | 402.964.0542 x117<\/option><option value='' ><\/option><option value='' ><\/option><\/select><\/div><\/li><li id=\"field_866_81\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_866_81'>TotalWellness Account Executive<\/label><div class='ginput_container 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