/*jslint nomen:false, debug:true, evil:true, vars:false, browser:true, forin:true, undef:false, white:false */
/**
* Includes a Form with javascript
* @param {Object} formId
* @param {Object} initialHeight
* @param {Object} iframeCode
*/
function FrameBuilder (formId, appendTo, initialHeight, iframeCode){
this.formId = formId;
this.initialHeight = initialHeight;
this.iframeCode = iframeCode;
this.frame = null;
this.timeInterval= 200;
this.appendTo = appendTo || false;
// initialize function for object
this.init = function(){
this.createFrame();
this.addFrameContent(this.iframeCode);
};
// Create the frame
this.createFrame = function(){
var htmlCode = "<"+"iframe src=\"\" allowtransparency=\"true\" frameborder=\"0\" name=\""+this.formId+"\" id=\""+this.formId+"\" style=\"width:100%; height:"+this.initialHeight+"px; border:none;\" scrolling=\"no\">";
if(this.appendTo === false){
document.write(htmlCode);
}else{
var tmp = document.createElement('div');
tmp.innerHTML = htmlCode;
var a = this.appendTo;
document.getElementById(a).appendChild(tmp.firstChild);
}
// also get the frame for future use.
this.frame = document.getElementById(this.formId);
// set the time on the on load event of the frame
this.addEvent(this.frame, 'load', this.bindMethod(this.setTimer, this));
};
// add event function for different browsers
this.addEvent = function( obj, type, fn ) {
if ( obj.attachEvent ) {
obj["e"+type+fn] = fn;
obj[type+fn] = function() { obj["e"+type+fn]( window.event ); };
obj.attachEvent( "on"+type, obj[type+fn] );
}
else{
obj.addEventListener( type, fn, false );
}
};
this.addFrameContent = function (string){
string = string.replace(new RegExp('src\\=\\"[^"]*captcha.php\"><\/scr'+'ipt>', 'gim'), 'src="http://api.recaptcha.net/js/recaptcha_ajax.js"><'+'div id="recaptcha_div"><'+'/div>'+
'<'+'style>#recaptcha_logo{ display:none;} #recaptcha_tagline{display:none;} #recaptcha_table{border:none !important;} .recaptchatable .recaptcha_image_cell, #recaptcha_table{ background-color:transparent !important; } <'+'/style>'+
'<'+'script defer="defer"> window.onload = function(){ Recaptcha.create("6Ld9UAgAAAAAAMon8zjt30tEZiGQZ4IIuWXLt1ky", "recaptcha_div", {theme: "clean",tabindex: 0,callback: function (){'+
'if (document.getElementById("uword")) { document.getElementById("uword").parentNode.removeChild(document.getElementById("uword")); } if (window["validate"] !== undefined) { if (document.getElementById("recaptcha_response_field")){ document.getElementById("recaptcha_response_field").onblur = function(){ validate(document.getElementById("recaptcha_response_field"), "Required"); } } } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_challenge_field")[0].setAttribute("name", "anum"); } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_response_field")[0].setAttribute("name", "qCap"); }}})'+
' }<'+'/script>');
string = string.replace(/(type="text\/javascript">)\s+(validate\(\"[^"]*"\);)/, '$1 jTime = setInterval(function(){if("validate" in window){$2clearTimeout(jTime);}}, 1000);');
var frameDocument = (this.frame.contentWindow) ? this.frame.contentWindow : (this.frame.contentDocument.document) ? this.frame.contentDocument.document : this.frame.contentDocument;
frameDocument.document.open();
frameDocument.document.write(string);
setTimeout( function(){
frameDocument.document.close();
try{
if('JotFormFrameLoaded' in window){
JotFormFrameLoaded();
}
}catch(e){}
},200);
};
this.setTimer = function(){
var self = this;
this.interval = setTimeout(function(){self.changeHeight();},this.timeInterval);
};
this.changeHeight = function (){
var actualHeight = this.getBodyHeight();
var currentHeight = this.getViewPortHeight();
if(actualHeight === undefined){
this.frame.style.height = "100%";
if(!this.frame.style.minHeight){
this.frame.style.minHeight = "300px";
}
}else if (Math.abs(actualHeight - currentHeight) > 18){
this.frame.style.height = (actualHeight)+"px";
}
this.setTimer();
};
this.bindMethod = function(method, scope) {
return function() {
method.apply(scope,arguments);
};
};
this.getBodyHeight = function (){
var height;
var scrollHeight;
var offsetHeight;
try{ // Prevent IE from throw errors
if (this.frame.contentWindow.document.height){
height = this.frame.contentWindow.document.height;
//Emre: to prevent "iframe height" problem (61059)
if (this.frame.contentWindow.document.body.scrollHeight){
height = scrollHeight = this.frame.contentWindow.document.body.scrollHeight;
}
if (this.frame.contentWindow.document.body.offsetHeight){
height = offsetHeight = this.frame.contentWindow.document.body.offsetHeight;
}
} else if (this.frame.contentWindow.document.body){
if (this.frame.contentWindow.document.body.scrollHeight){
height = scrollHeight = this.frame.contentWindow.document.body.scrollHeight;
}
if (this.frame.contentWindow.document.body.offsetHeight){
height = offsetHeight = this.frame.contentWindow.document.body.offsetHeight;
}
if (scrollHeight && offsetHeight){
height = Math.max(scrollHeight, offsetHeight);
}
}
}catch(e){ }
return height;
};
this.getViewPortHeight = function(){
var height = 0;
try{ // Prevent IE from throw errors
if (this.frame.contentWindow.window.innerHeight)
{
height = this.frame.contentWindow.window.innerHeight - 18;
}
else if ((this.frame.contentWindow.document.documentElement) &&
(this.frame.contentWindow.document.documentElement.clientHeight))
{
height = this.frame.contentWindow.document.documentElement.clientHeight;
}
else if ((this.frame.contentWindow.document.body) &&
(this.frame.contentWindow.document.body.clientHeight))
{
height = this.frame.contentWindow.document.body.clientHeight;
}
}catch(e){ }
return height;
};
this.init();
}
FrameBuilder.get = [];
var i10733219336 = new FrameBuilder("10733219336", false, "", "\n\n\n\n\nForm<\/title>\n<link href=\"http:\/\/max.jotfor.ms\/min\/g=formCss?3.0.2435\" rel=\"stylesheet\" type=\"text\/css\" \/>\n<style type=\"text\/css\">\n .form-label{\n width:150px !important;\n }\n .form-label-left{\n width:150px !important;\n }\n .form-line{\n padding:5px;\n }\n .form-label-right{\n width:150px !important;\n }\n body, html{\n margin:0;\n padding:0;\n background:white;\n }\n\n .form-all{\n margin:0px auto;\n padding-top:20px;\n width:690px;\n background:white;\n color:black !important;\n font-family:Verdana;\n font-size:12px;\n }\n<\/style>\n\n<script src=\"http:\/\/max.jotfor.ms\/min\/g=jotform?3.0.2435\" type=\"text\/javascript\"><\/script>\n<script type=\"text\/javascript\">\n var jsTime = setInterval(function(){try{\n JotForm.jsForm = true;\n\n JotForm.init(function(){\n JotForm.description('input_51', '20');\n JotForm.description('input_78', '20');\n JotForm.description('input_52', '20');\n JotForm.description('input_82', '20');\n JotForm.initCaptcha('input_53');\n });\n\n clearInterval(jsTime);\n }catch(e){}}, 1000);\n<\/script>\n<\/head>\n<body>\n<form class=\"jotform-form\" action=\"http:\/\/submit.jotform.com\/submit.php\" method=\"post\" name=\"form_10733219336\" id=\"10733219336\" accept-charset=\"utf-8\">\n <input type=\"hidden\" name=\"formID\" value=\"10733219336\" \/>\n <div class=\"form-all\">\n <ul class=\"form-section\">\n <li class=\"form-line\" id=\"id_67\">\n <div id=\"cid_67\" class=\"form-input-wide\">\n <div id=\"text_67\" class=\"form-html\">\n WELCOME TO HAMPTON PARK VETS AND THANK YOU FOR REGISTERING ONLINE\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_73\">\n <label class=\"form-label-left\" id=\"label_73\" for=\"input_73\"> Surname: <\/label>\n <div id=\"cid_73\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_73\" name=\"q73_surname\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_77\">\n <label class=\"form-label-left\" id=\"label_77\" for=\"input_77\"> First Name: <\/label>\n <div id=\"cid_77\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_77\" name=\"q77_firstName\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_72\">\n <label class=\"form-label-left\" id=\"label_72\" for=\"input_72\"> Initials\/Title: <\/label>\n <div id=\"cid_72\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_72\" name=\"q72_initialstitle\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_71\">\n <label class=\"form-label-left\" id=\"label_71\" for=\"input_71\"> Address: <\/label>\n <div id=\"cid_71\" class=\"form-input\">\n <textarea id=\"input_71\" class=\"form-textarea\" name=\"q71_address\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_2\">\n <label class=\"form-label-left\" id=\"label_2\" for=\"input_2\"> Postcode: <\/label>\n <div id=\"cid_2\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_2\" name=\"q2_postcode\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_10\">\n <label class=\"form-label-left\" id=\"label_10\" for=\"input_10\"> Home Phone No: <\/label>\n <div id=\"cid_10\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_10\" name=\"q10_homePhone\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_11\">\n <label class=\"form-label-left\" id=\"label_11\" for=\"input_11\"> Other Phone No: <\/label>\n <div id=\"cid_11\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_11\" name=\"q11_otherPhone\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_1\">\n <label class=\"form-label-left\" id=\"label_1\" for=\"input_1\">\n Email Address:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_1\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required, Email]\" id=\"input_1\" name=\"q1_emailAddress\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_13\">\n <label class=\"form-label-left\" id=\"label_13\" for=\"input_13\"> Where did you hear about us: - (Please Specify) <\/label>\n <div id=\"cid_13\" class=\"form-input\">\n <textarea id=\"input_13\" class=\"form-textarea\" name=\"q13_whereDid\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_15\">\n <label class=\"form-label-left\" id=\"label_15\" for=\"input_15\"> How did you find our Website: <\/label>\n <div id=\"cid_15\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_15\" name=\"q15_howDid\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_68\">\n <div id=\"cid_68\" class=\"form-input-wide\">\n <div id=\"text_68\" class=\"form-html\">\n PET DETAILS\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_16\">\n <label class=\"form-label-left\" id=\"label_16\" for=\"input_16\"> Number of Pets <\/label>\n <div id=\"cid_16\" class=\"form-input\">\n <select class=\"form-dropdown\" style=\"width:150px\" id=\"input_16\" name=\"q16_numberOf\">\n <option> <\/option>\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3 or more\"> 3 or more <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_22\">\n <label class=\"form-label-left\" id=\"label_22\" for=\"input_22\"> Pet 1 Name: <\/label>\n <div id=\"cid_22\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_22\" name=\"q22_pet1\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_75\">\n <label class=\"form-label-left\" id=\"label_75\" for=\"input_75\"> Pet 1 Species: <\/label>\n <div id=\"cid_75\" class=\"form-input\">\n <select class=\"form-dropdown\" style=\"width:150px\" id=\"input_75\" name=\"q75_pet175\">\n <option> <\/option>\n <option value=\"Dog\"> Dog <\/option>\n <option value=\"Cat\"> Cat <\/option>\n <option value=\"Rabbit\"> Rabbit <\/option>\n <option value=\"Guinea-Pig\"> Guinea-Pig <\/option>\n <option value=\"Hamster\"> Hamster <\/option>\n <option value=\"Reptile\"> Reptile <\/option>\n <option value=\"Bird\"> Bird <\/option>\n <option value=\"Other\"> Other <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_24\">\n <label class=\"form-label-left\" id=\"label_24\" for=\"input_24\"> Pet 1 Breed: <\/label>\n <div id=\"cid_24\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_24\" name=\"q24_pet124\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_79\">\n <label class=\"form-label-left\" id=\"label_79\" for=\"input_79\"> Pet 1 Sex <\/label>\n <div id=\"cid_79\" class=\"form-input\">\n <select class=\"form-dropdown\" style=\"width:150px\" id=\"input_79\" name=\"q79_pet179\">\n <option> <\/option>\n <option value=\"Female\"> Female <\/option>\n <option value=\"Male\"> Male <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_32\">\n <label class=\"form-label-left\" id=\"label_32\" for=\"input_32\"> Pet 1 Neutered: <\/label>\n <div id=\"cid_32\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_32_0\" name=\"q32_pet132[]\" value=\"Yes\" \/>\n <label for=\"input_32_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_32_1\" name=\"q32_pet132[]\" value=\"No\" \/>\n <label for=\"input_32_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_27\">\n <label class=\"form-label-left\" id=\"label_27\" for=\"input_27\"> Pet 1 Colour: <\/label>\n <div id=\"cid_27\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_27\" name=\"q27_pet127\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_51\">\n <label class=\"form-label-left\" id=\"label_51\" for=\"input_51\"> Pet 1 Age\/Date of Birth: <\/label>\n <div id=\"cid_51\" class=\"form-input\"><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q51_pet151[month]\" id=\"input_51_month\">\n <option> <\/option>\n <option value=\"January\"> January <\/option>\n <option value=\"February\"> February <\/option>\n <option value=\"March\"> March <\/option>\n <option value=\"April\"> April <\/option>\n <option value=\"May\"> May <\/option>\n <option value=\"June\"> June <\/option>\n <option value=\"July\"> July <\/option>\n <option value=\"August\"> August <\/option>\n <option value=\"September\"> September <\/option>\n <option value=\"October\"> October <\/option>\n <option value=\"November\"> November <\/option>\n <option value=\"December\"> December <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_51_month\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q51_pet151[day]\" id=\"input_51_day\">\n <option> <\/option>\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <option value=\"11\"> 11 <\/option>\n <option value=\"12\"> 12 <\/option>\n <option value=\"13\"> 13 <\/option>\n <option value=\"14\"> 14 <\/option>\n <option value=\"15\"> 15 <\/option>\n <option value=\"16\"> 16 <\/option>\n <option value=\"17\"> 17 <\/option>\n <option value=\"18\"> 18 <\/option>\n <option value=\"19\"> 19 <\/option>\n <option value=\"20\"> 20 <\/option>\n <option value=\"21\"> 21 <\/option>\n <option value=\"22\"> 22 <\/option>\n <option value=\"23\"> 23 <\/option>\n <option value=\"24\"> 24 <\/option>\n <option value=\"25\"> 25 <\/option>\n <option value=\"26\"> 26 <\/option>\n <option value=\"27\"> 27 <\/option>\n <option value=\"28\"> 28 <\/option>\n <option value=\"29\"> 29 <\/option>\n <option value=\"30\"> 30 <\/option>\n <option value=\"31\"> 31 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_51_day\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q51_pet151[year]\" id=\"input_51_year\">\n <option> <\/option>\n <option value=\"2016\"> 2016 <\/option>\n <option value=\"2015\"> 2015 <\/option>\n <option value=\"2014\"> 2014 <\/option>\n <option value=\"2013\"> 2013 <\/option>\n <option value=\"2012\"> 2012 <\/option>\n <option value=\"2011\"> 2011 <\/option>\n <option value=\"2010\"> 2010 <\/option>\n <option value=\"2009\"> 2009 <\/option>\n <option value=\"2008\"> 2008 <\/option>\n <option value=\"2007\"> 2007 <\/option>\n <option value=\"2006\"> 2006 <\/option>\n <option value=\"2005\"> 2005 <\/option>\n <option value=\"2004\"> 2004 <\/option>\n <option value=\"2003\"> 2003 <\/option>\n <option value=\"2002\"> 2002 <\/option>\n <option value=\"2001\"> 2001 <\/option>\n <option value=\"2000\"> 2000 <\/option>\n <option value=\"1999\"> 1999 <\/option>\n <option value=\"1998\"> 1998 <\/option>\n <option value=\"1997\"> 1997 <\/option>\n <option value=\"1996\"> 1996 <\/option>\n <option value=\"1995\"> 1995 <\/option>\n <option value=\"1994\"> 1994 <\/option>\n <option value=\"1993\"> 1993 <\/option>\n <option value=\"1992\"> 1992 <\/option>\n <option value=\"1991\"> 1991 <\/option>\n <option value=\"1990\"> 1990 <\/option>\n <option value=\"1989\"> 1989 <\/option>\n <option value=\"1988\"> 1988 <\/option>\n <option value=\"1987\"> 1987 <\/option>\n <option value=\"1986\"> 1986 <\/option>\n <option value=\"1985\"> 1985 <\/option>\n <option value=\"1984\"> 1984 <\/option>\n <option value=\"1983\"> 1983 <\/option>\n <option value=\"1982\"> 1982 <\/option>\n <option value=\"1981\"> 1981 <\/option>\n <option value=\"1980\"> 1980 <\/option>\n <option value=\"1979\"> 1979 <\/option>\n <option value=\"1978\"> 1978 <\/option>\n <option value=\"1977\"> 1977 <\/option>\n <option value=\"1976\"> 1976 <\/option>\n <option value=\"1975\"> 1975 <\/option>\n <option value=\"1974\"> 1974 <\/option>\n <option value=\"1973\"> 1973 <\/option>\n <option value=\"1972\"> 1972 <\/option>\n <option value=\"1971\"> 1971 <\/option>\n <option value=\"1970\"> 1970 <\/option>\n <option value=\"1969\"> 1969 <\/option>\n <option value=\"1968\"> 1968 <\/option>\n <option value=\"1967\"> 1967 <\/option>\n <option value=\"1966\"> 1966 <\/option>\n <option value=\"1965\"> 1965 <\/option>\n <option value=\"1964\"> 1964 <\/option>\n <option value=\"1963\"> 1963 <\/option>\n <option value=\"1962\"> 1962 <\/option>\n <option value=\"1961\"> 1961 <\/option>\n <option value=\"1960\"> 1960 <\/option>\n <option value=\"1959\"> 1959 <\/option>\n <option value=\"1958\"> 1958 <\/option>\n <option value=\"1957\"> 1957 <\/option>\n <option value=\"1956\"> 1956 <\/option>\n <option value=\"1955\"> 1955 <\/option>\n <option value=\"1954\"> 1954 <\/option>\n <option value=\"1953\"> 1953 <\/option>\n <option value=\"1952\"> 1952 <\/option>\n <option value=\"1951\"> 1951 <\/option>\n <option value=\"1950\"> 1950 <\/option>\n <option value=\"1949\"> 1949 <\/option>\n <option value=\"1948\"> 1948 <\/option>\n <option value=\"1947\"> 1947 <\/option>\n <option value=\"1946\"> 1946 <\/option>\n <option value=\"1945\"> 1945 <\/option>\n <option value=\"1944\"> 1944 <\/option>\n <option value=\"1943\"> 1943 <\/option>\n <option value=\"1942\"> 1942 <\/option>\n <option value=\"1941\"> 1941 <\/option>\n <option value=\"1940\"> 1940 <\/option>\n <option value=\"1939\"> 1939 <\/option>\n <option value=\"1938\"> 1938 <\/option>\n <option value=\"1937\"> 1937 <\/option>\n <option value=\"1936\"> 1936 <\/option>\n <option value=\"1935\"> 1935 <\/option>\n <option value=\"1934\"> 1934 <\/option>\n <option value=\"1933\"> 1933 <\/option>\n <option value=\"1932\"> 1932 <\/option>\n <option value=\"1931\"> 1931 <\/option>\n <option value=\"1930\"> 1930 <\/option>\n <option value=\"1929\"> 1929 <\/option>\n <option value=\"1928\"> 1928 <\/option>\n <option value=\"1927\"> 1927 <\/option>\n <option value=\"1926\"> 1926 <\/option>\n <option value=\"1925\"> 1925 <\/option>\n <option value=\"1924\"> 1924 <\/option>\n <option value=\"1923\"> 1923 <\/option>\n <option value=\"1922\"> 1922 <\/option>\n <option value=\"1921\"> 1921 <\/option>\n <option value=\"1920\"> 1920 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_51_year\" id=\"sublabel_year\"> Year <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_78\">\n <label class=\"form-label-left\" id=\"label_78\" for=\"input_78\"> Pet 1 LAST VACCINATION: <\/label>\n <div id=\"cid_78\" class=\"form-input\"><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q78_pet178[month]\" id=\"input_78_month\">\n <option> <\/option>\n <option value=\"January\"> January <\/option>\n <option value=\"February\"> February <\/option>\n <option value=\"March\"> March <\/option>\n <option value=\"April\"> April <\/option>\n <option value=\"May\"> May <\/option>\n <option value=\"June\"> June <\/option>\n <option value=\"July\"> July <\/option>\n <option value=\"August\"> August <\/option>\n <option value=\"September\"> September <\/option>\n <option value=\"October\"> October <\/option>\n <option value=\"November\"> November <\/option>\n <option value=\"December\"> December <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_78_month\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q78_pet178[day]\" id=\"input_78_day\">\n <option> <\/option>\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <option value=\"11\"> 11 <\/option>\n <option value=\"12\"> 12 <\/option>\n <option value=\"13\"> 13 <\/option>\n <option value=\"14\"> 14 <\/option>\n <option value=\"15\"> 15 <\/option>\n <option value=\"16\"> 16 <\/option>\n <option value=\"17\"> 17 <\/option>\n <option value=\"18\"> 18 <\/option>\n <option value=\"19\"> 19 <\/option>\n <option value=\"20\"> 20 <\/option>\n <option value=\"21\"> 21 <\/option>\n <option value=\"22\"> 22 <\/option>\n <option value=\"23\"> 23 <\/option>\n <option value=\"24\"> 24 <\/option>\n <option value=\"25\"> 25 <\/option>\n <option value=\"26\"> 26 <\/option>\n <option value=\"27\"> 27 <\/option>\n <option value=\"28\"> 28 <\/option>\n <option value=\"29\"> 29 <\/option>\n <option value=\"30\"> 30 <\/option>\n <option value=\"31\"> 31 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_78_day\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q78_pet178[year]\" id=\"input_78_year\">\n <option> <\/option>\n <option value=\"2016\"> 2016 <\/option>\n <option value=\"2015\"> 2015 <\/option>\n <option value=\"2014\"> 2014 <\/option>\n <option value=\"2013\"> 2013 <\/option>\n <option value=\"2012\"> 2012 <\/option>\n <option value=\"2011\"> 2011 <\/option>\n <option value=\"2010\"> 2010 <\/option>\n <option value=\"2009\"> 2009 <\/option>\n <option value=\"2008\"> 2008 <\/option>\n <option value=\"2007\"> 2007 <\/option>\n <option value=\"2006\"> 2006 <\/option>\n <option value=\"2005\"> 2005 <\/option>\n <option value=\"2004\"> 2004 <\/option>\n <option value=\"2003\"> 2003 <\/option>\n <option value=\"2002\"> 2002 <\/option>\n <option value=\"2001\"> 2001 <\/option>\n <option value=\"2000\"> 2000 <\/option>\n <option value=\"1999\"> 1999 <\/option>\n <option value=\"1998\"> 1998 <\/option>\n <option value=\"1997\"> 1997 <\/option>\n <option value=\"1996\"> 1996 <\/option>\n <option value=\"1995\"> 1995 <\/option>\n <option value=\"1994\"> 1994 <\/option>\n <option value=\"1993\"> 1993 <\/option>\n <option value=\"1992\"> 1992 <\/option>\n <option value=\"1991\"> 1991 <\/option>\n <option value=\"1990\"> 1990 <\/option>\n <option value=\"1989\"> 1989 <\/option>\n <option value=\"1988\"> 1988 <\/option>\n <option value=\"1987\"> 1987 <\/option>\n <option value=\"1986\"> 1986 <\/option>\n <option value=\"1985\"> 1985 <\/option>\n <option value=\"1984\"> 1984 <\/option>\n <option value=\"1983\"> 1983 <\/option>\n <option value=\"1982\"> 1982 <\/option>\n <option value=\"1981\"> 1981 <\/option>\n <option value=\"1980\"> 1980 <\/option>\n <option value=\"1979\"> 1979 <\/option>\n <option value=\"1978\"> 1978 <\/option>\n <option value=\"1977\"> 1977 <\/option>\n <option value=\"1976\"> 1976 <\/option>\n <option value=\"1975\"> 1975 <\/option>\n <option value=\"1974\"> 1974 <\/option>\n <option value=\"1973\"> 1973 <\/option>\n <option value=\"1972\"> 1972 <\/option>\n <option value=\"1971\"> 1971 <\/option>\n <option value=\"1970\"> 1970 <\/option>\n <option value=\"1969\"> 1969 <\/option>\n <option value=\"1968\"> 1968 <\/option>\n <option value=\"1967\"> 1967 <\/option>\n <option value=\"1966\"> 1966 <\/option>\n <option value=\"1965\"> 1965 <\/option>\n <option value=\"1964\"> 1964 <\/option>\n <option value=\"1963\"> 1963 <\/option>\n <option value=\"1962\"> 1962 <\/option>\n <option value=\"1961\"> 1961 <\/option>\n <option value=\"1960\"> 1960 <\/option>\n <option value=\"1959\"> 1959 <\/option>\n <option value=\"1958\"> 1958 <\/option>\n <option value=\"1957\"> 1957 <\/option>\n <option value=\"1956\"> 1956 <\/option>\n <option value=\"1955\"> 1955 <\/option>\n <option value=\"1954\"> 1954 <\/option>\n <option value=\"1953\"> 1953 <\/option>\n <option value=\"1952\"> 1952 <\/option>\n <option value=\"1951\"> 1951 <\/option>\n <option value=\"1950\"> 1950 <\/option>\n <option value=\"1949\"> 1949 <\/option>\n <option value=\"1948\"> 1948 <\/option>\n <option value=\"1947\"> 1947 <\/option>\n <option value=\"1946\"> 1946 <\/option>\n <option value=\"1945\"> 1945 <\/option>\n <option value=\"1944\"> 1944 <\/option>\n <option value=\"1943\"> 1943 <\/option>\n <option value=\"1942\"> 1942 <\/option>\n <option value=\"1941\"> 1941 <\/option>\n <option value=\"1940\"> 1940 <\/option>\n <option value=\"1939\"> 1939 <\/option>\n <option value=\"1938\"> 1938 <\/option>\n <option value=\"1937\"> 1937 <\/option>\n <option value=\"1936\"> 1936 <\/option>\n <option value=\"1935\"> 1935 <\/option>\n <option value=\"1934\"> 1934 <\/option>\n <option value=\"1933\"> 1933 <\/option>\n <option value=\"1932\"> 1932 <\/option>\n <option value=\"1931\"> 1931 <\/option>\n <option value=\"1930\"> 1930 <\/option>\n <option value=\"1929\"> 1929 <\/option>\n <option value=\"1928\"> 1928 <\/option>\n <option value=\"1927\"> 1927 <\/option>\n <option value=\"1926\"> 1926 <\/option>\n <option value=\"1925\"> 1925 <\/option>\n <option value=\"1924\"> 1924 <\/option>\n <option value=\"1923\"> 1923 <\/option>\n <option value=\"1922\"> 1922 <\/option>\n <option value=\"1921\"> 1921 <\/option>\n <option value=\"1920\"> 1920 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_78_year\" id=\"sublabel_year\"> Year <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_30\">\n <label class=\"form-label-left\" id=\"label_30\" for=\"input_30\"> Which Insurance Company are you insured with: <\/label>\n <div id=\"cid_30\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_30\" name=\"q30_whichInsurance\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_31\">\n <label class=\"form-label-left\" id=\"label_31\" for=\"input_31\"> CURRENT MEDICATIONS AND\/OR RECENT TREATMENTS: <\/label>\n <div id=\"cid_31\" class=\"form-input\">\n <textarea id=\"input_31\" class=\"form-textarea\" name=\"q31_currentMedications\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_34\">\n <div id=\"cid_34\" class=\"form-input-wide\">\n <div id=\"text_34\" class=\"form-html\">\n Please note that pets requiring repeat prescriptions will need to be assessed every four months for which there is a prescription evaluation fee.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_35\">\n <label class=\"form-label-left\" id=\"label_35\" for=\"input_35\"> Pet 2 Name: <\/label>\n <div id=\"cid_35\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_35\" name=\"q35_pet2\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_76\">\n <label class=\"form-label-left\" id=\"label_76\" for=\"input_76\"> Pet 2 Species: <\/label>\n <div id=\"cid_76\" class=\"form-input\">\n <select class=\"form-dropdown\" style=\"width:150px\" id=\"input_76\" name=\"q76_pet276\">\n <option> <\/option>\n <option value=\"Dog\"> Dog <\/option>\n <option value=\"Cat\"> Cat <\/option>\n <option value=\"Rabbit\"> Rabbit <\/option>\n <option value=\"Guinea-Pig\"> Guinea-Pig <\/option>\n <option value=\"Hamster\"> Hamster <\/option>\n <option value=\"Reptile\"> Reptile <\/option>\n <option value=\"Bird\"> Bird <\/option>\n <option value=\"Other\"> Other <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_37\">\n <label class=\"form-label-left\" id=\"label_37\" for=\"input_37\"> Pet 2 Breed: <\/label>\n <div id=\"cid_37\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_37\" name=\"q37_pet237\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_80\">\n <label class=\"form-label-left\" id=\"label_80\" for=\"input_80\"> Pet 2 Sex: <\/label>\n <div id=\"cid_80\" class=\"form-input\">\n <select class=\"form-dropdown\" style=\"width:150px\" id=\"input_80\" name=\"q80_pet280\">\n <option> <\/option>\n <option value=\"Male\"> Male <\/option>\n <option value=\"Female\"> Female <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_39\">\n <label class=\"form-label-left\" id=\"label_39\" for=\"input_39\"> Pet 2 Neutered: <\/label>\n <div id=\"cid_39\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_39_0\" name=\"q39_pet239[]\" value=\"Yes\" \/>\n <label for=\"input_39_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_39_1\" name=\"q39_pet239[]\" value=\"No\" \/>\n <label for=\"input_39_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_40\">\n <label class=\"form-label-left\" id=\"label_40\" for=\"input_40\"> Pet 2 Colour: <\/label>\n <div id=\"cid_40\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_40\" name=\"q40_pet240\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_52\">\n <label class=\"form-label-left\" id=\"label_52\" for=\"input_52\"> Pet 2 Age\/Date of Birth: <\/label>\n <div id=\"cid_52\" class=\"form-input\"><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q52_pet252[month]\" id=\"input_52_month\">\n <option> <\/option>\n <option value=\"January\"> January <\/option>\n <option value=\"February\"> February <\/option>\n <option value=\"March\"> March <\/option>\n <option value=\"April\"> April <\/option>\n <option value=\"May\"> May <\/option>\n <option value=\"June\"> June <\/option>\n <option value=\"July\"> July <\/option>\n <option value=\"August\"> August <\/option>\n <option value=\"September\"> September <\/option>\n <option value=\"October\"> October <\/option>\n <option value=\"November\"> November <\/option>\n <option value=\"December\"> December <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_52_month\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q52_pet252[day]\" id=\"input_52_day\">\n <option> <\/option>\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <option value=\"11\"> 11 <\/option>\n <option value=\"12\"> 12 <\/option>\n <option value=\"13\"> 13 <\/option>\n <option value=\"14\"> 14 <\/option>\n <option value=\"15\"> 15 <\/option>\n <option value=\"16\"> 16 <\/option>\n <option value=\"17\"> 17 <\/option>\n <option value=\"18\"> 18 <\/option>\n <option value=\"19\"> 19 <\/option>\n <option value=\"20\"> 20 <\/option>\n <option value=\"21\"> 21 <\/option>\n <option value=\"22\"> 22 <\/option>\n <option value=\"23\"> 23 <\/option>\n <option value=\"24\"> 24 <\/option>\n <option value=\"25\"> 25 <\/option>\n <option value=\"26\"> 26 <\/option>\n <option value=\"27\"> 27 <\/option>\n <option value=\"28\"> 28 <\/option>\n <option value=\"29\"> 29 <\/option>\n <option value=\"30\"> 30 <\/option>\n <option value=\"31\"> 31 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_52_day\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q52_pet252[year]\" id=\"input_52_year\">\n <option> <\/option>\n <option value=\"2016\"> 2016 <\/option>\n <option value=\"2015\"> 2015 <\/option>\n <option value=\"2014\"> 2014 <\/option>\n <option value=\"2013\"> 2013 <\/option>\n <option value=\"2012\"> 2012 <\/option>\n <option value=\"2011\"> 2011 <\/option>\n <option value=\"2010\"> 2010 <\/option>\n <option value=\"2009\"> 2009 <\/option>\n <option value=\"2008\"> 2008 <\/option>\n <option value=\"2007\"> 2007 <\/option>\n <option value=\"2006\"> 2006 <\/option>\n <option value=\"2005\"> 2005 <\/option>\n <option value=\"2004\"> 2004 <\/option>\n <option value=\"2003\"> 2003 <\/option>\n <option value=\"2002\"> 2002 <\/option>\n <option value=\"2001\"> 2001 <\/option>\n <option value=\"2000\"> 2000 <\/option>\n <option value=\"1999\"> 1999 <\/option>\n <option value=\"1998\"> 1998 <\/option>\n <option value=\"1997\"> 1997 <\/option>\n <option value=\"1996\"> 1996 <\/option>\n <option value=\"1995\"> 1995 <\/option>\n <option value=\"1994\"> 1994 <\/option>\n <option value=\"1993\"> 1993 <\/option>\n <option value=\"1992\"> 1992 <\/option>\n <option value=\"1991\"> 1991 <\/option>\n <option value=\"1990\"> 1990 <\/option>\n <option value=\"1989\"> 1989 <\/option>\n <option value=\"1988\"> 1988 <\/option>\n <option value=\"1987\"> 1987 <\/option>\n <option value=\"1986\"> 1986 <\/option>\n <option value=\"1985\"> 1985 <\/option>\n <option value=\"1984\"> 1984 <\/option>\n <option value=\"1983\"> 1983 <\/option>\n <option value=\"1982\"> 1982 <\/option>\n <option value=\"1981\"> 1981 <\/option>\n <option value=\"1980\"> 1980 <\/option>\n <option value=\"1979\"> 1979 <\/option>\n <option value=\"1978\"> 1978 <\/option>\n <option value=\"1977\"> 1977 <\/option>\n <option value=\"1976\"> 1976 <\/option>\n <option value=\"1975\"> 1975 <\/option>\n <option value=\"1974\"> 1974 <\/option>\n <option value=\"1973\"> 1973 <\/option>\n <option value=\"1972\"> 1972 <\/option>\n <option value=\"1971\"> 1971 <\/option>\n <option value=\"1970\"> 1970 <\/option>\n <option value=\"1969\"> 1969 <\/option>\n <option value=\"1968\"> 1968 <\/option>\n <option value=\"1967\"> 1967 <\/option>\n <option value=\"1966\"> 1966 <\/option>\n <option value=\"1965\"> 1965 <\/option>\n <option value=\"1964\"> 1964 <\/option>\n <option value=\"1963\"> 1963 <\/option>\n <option value=\"1962\"> 1962 <\/option>\n <option value=\"1961\"> 1961 <\/option>\n <option value=\"1960\"> 1960 <\/option>\n <option value=\"1959\"> 1959 <\/option>\n <option value=\"1958\"> 1958 <\/option>\n <option value=\"1957\"> 1957 <\/option>\n <option value=\"1956\"> 1956 <\/option>\n <option value=\"1955\"> 1955 <\/option>\n <option value=\"1954\"> 1954 <\/option>\n <option value=\"1953\"> 1953 <\/option>\n <option value=\"1952\"> 1952 <\/option>\n <option value=\"1951\"> 1951 <\/option>\n <option value=\"1950\"> 1950 <\/option>\n <option value=\"1949\"> 1949 <\/option>\n <option value=\"1948\"> 1948 <\/option>\n <option value=\"1947\"> 1947 <\/option>\n <option value=\"1946\"> 1946 <\/option>\n <option value=\"1945\"> 1945 <\/option>\n <option value=\"1944\"> 1944 <\/option>\n <option value=\"1943\"> 1943 <\/option>\n <option value=\"1942\"> 1942 <\/option>\n <option value=\"1941\"> 1941 <\/option>\n <option value=\"1940\"> 1940 <\/option>\n <option value=\"1939\"> 1939 <\/option>\n <option value=\"1938\"> 1938 <\/option>\n <option value=\"1937\"> 1937 <\/option>\n <option value=\"1936\"> 1936 <\/option>\n <option value=\"1935\"> 1935 <\/option>\n <option value=\"1934\"> 1934 <\/option>\n <option value=\"1933\"> 1933 <\/option>\n <option value=\"1932\"> 1932 <\/option>\n <option value=\"1931\"> 1931 <\/option>\n <option value=\"1930\"> 1930 <\/option>\n <option value=\"1929\"> 1929 <\/option>\n <option value=\"1928\"> 1928 <\/option>\n <option value=\"1927\"> 1927 <\/option>\n <option value=\"1926\"> 1926 <\/option>\n <option value=\"1925\"> 1925 <\/option>\n <option value=\"1924\"> 1924 <\/option>\n <option value=\"1923\"> 1923 <\/option>\n <option value=\"1922\"> 1922 <\/option>\n <option value=\"1921\"> 1921 <\/option>\n <option value=\"1920\"> 1920 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_52_year\" id=\"sublabel_year\"> Year <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_82\">\n <label class=\"form-label-left\" id=\"label_82\" for=\"input_82\"> Pet 2 LAST VACCINATION: <\/label>\n <div id=\"cid_82\" class=\"form-input\"><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q82_pet282[month]\" id=\"input_82_month\">\n <option> <\/option>\n <option value=\"January\"> January <\/option>\n <option value=\"February\"> February <\/option>\n <option value=\"March\"> March <\/option>\n <option value=\"April\"> April <\/option>\n <option value=\"May\"> May <\/option>\n <option value=\"June\"> June <\/option>\n <option value=\"July\"> July <\/option>\n <option value=\"August\"> August <\/option>\n <option value=\"September\"> September <\/option>\n <option value=\"October\"> October <\/option>\n <option value=\"November\"> November <\/option>\n <option value=\"December\"> December <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_82_month\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q82_pet282[day]\" id=\"input_82_day\">\n <option> <\/option>\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <option value=\"11\"> 11 <\/option>\n <option value=\"12\"> 12 <\/option>\n <option value=\"13\"> 13 <\/option>\n <option value=\"14\"> 14 <\/option>\n <option value=\"15\"> 15 <\/option>\n <option value=\"16\"> 16 <\/option>\n <option value=\"17\"> 17 <\/option>\n <option value=\"18\"> 18 <\/option>\n <option value=\"19\"> 19 <\/option>\n <option value=\"20\"> 20 <\/option>\n <option value=\"21\"> 21 <\/option>\n <option value=\"22\"> 22 <\/option>\n <option value=\"23\"> 23 <\/option>\n <option value=\"24\"> 24 <\/option>\n <option value=\"25\"> 25 <\/option>\n <option value=\"26\"> 26 <\/option>\n <option value=\"27\"> 27 <\/option>\n <option value=\"28\"> 28 <\/option>\n <option value=\"29\"> 29 <\/option>\n <option value=\"30\"> 30 <\/option>\n <option value=\"31\"> 31 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_82_day\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q82_pet282[year]\" id=\"input_82_year\">\n <option> <\/option>\n <option value=\"2016\"> 2016 <\/option>\n <option value=\"2015\"> 2015 <\/option>\n <option value=\"2014\"> 2014 <\/option>\n <option value=\"2013\"> 2013 <\/option>\n <option value=\"2012\"> 2012 <\/option>\n <option value=\"2011\"> 2011 <\/option>\n <option value=\"2010\"> 2010 <\/option>\n <option value=\"2009\"> 2009 <\/option>\n <option value=\"2008\"> 2008 <\/option>\n <option value=\"2007\"> 2007 <\/option>\n <option value=\"2006\"> 2006 <\/option>\n <option value=\"2005\"> 2005 <\/option>\n <option value=\"2004\"> 2004 <\/option>\n <option value=\"2003\"> 2003 <\/option>\n <option value=\"2002\"> 2002 <\/option>\n <option value=\"2001\"> 2001 <\/option>\n <option value=\"2000\"> 2000 <\/option>\n <option value=\"1999\"> 1999 <\/option>\n <option value=\"1998\"> 1998 <\/option>\n <option value=\"1997\"> 1997 <\/option>\n <option value=\"1996\"> 1996 <\/option>\n <option value=\"1995\"> 1995 <\/option>\n <option value=\"1994\"> 1994 <\/option>\n <option value=\"1993\"> 1993 <\/option>\n <option value=\"1992\"> 1992 <\/option>\n <option value=\"1991\"> 1991 <\/option>\n <option value=\"1990\"> 1990 <\/option>\n <option value=\"1989\"> 1989 <\/option>\n <option value=\"1988\"> 1988 <\/option>\n <option value=\"1987\"> 1987 <\/option>\n <option value=\"1986\"> 1986 <\/option>\n <option value=\"1985\"> 1985 <\/option>\n <option value=\"1984\"> 1984 <\/option>\n <option value=\"1983\"> 1983 <\/option>\n <option value=\"1982\"> 1982 <\/option>\n <option value=\"1981\"> 1981 <\/option>\n <option value=\"1980\"> 1980 <\/option>\n <option value=\"1979\"> 1979 <\/option>\n <option value=\"1978\"> 1978 <\/option>\n <option value=\"1977\"> 1977 <\/option>\n <option value=\"1976\"> 1976 <\/option>\n <option value=\"1975\"> 1975 <\/option>\n <option value=\"1974\"> 1974 <\/option>\n <option value=\"1973\"> 1973 <\/option>\n <option value=\"1972\"> 1972 <\/option>\n <option value=\"1971\"> 1971 <\/option>\n <option value=\"1970\"> 1970 <\/option>\n <option value=\"1969\"> 1969 <\/option>\n <option value=\"1968\"> 1968 <\/option>\n <option value=\"1967\"> 1967 <\/option>\n <option value=\"1966\"> 1966 <\/option>\n <option value=\"1965\"> 1965 <\/option>\n <option value=\"1964\"> 1964 <\/option>\n <option value=\"1963\"> 1963 <\/option>\n <option value=\"1962\"> 1962 <\/option>\n <option value=\"1961\"> 1961 <\/option>\n <option value=\"1960\"> 1960 <\/option>\n <option value=\"1959\"> 1959 <\/option>\n <option value=\"1958\"> 1958 <\/option>\n <option value=\"1957\"> 1957 <\/option>\n <option value=\"1956\"> 1956 <\/option>\n <option value=\"1955\"> 1955 <\/option>\n <option value=\"1954\"> 1954 <\/option>\n <option value=\"1953\"> 1953 <\/option>\n <option value=\"1952\"> 1952 <\/option>\n <option value=\"1951\"> 1951 <\/option>\n <option value=\"1950\"> 1950 <\/option>\n <option value=\"1949\"> 1949 <\/option>\n <option value=\"1948\"> 1948 <\/option>\n <option value=\"1947\"> 1947 <\/option>\n <option value=\"1946\"> 1946 <\/option>\n <option value=\"1945\"> 1945 <\/option>\n <option value=\"1944\"> 1944 <\/option>\n <option value=\"1943\"> 1943 <\/option>\n <option value=\"1942\"> 1942 <\/option>\n <option value=\"1941\"> 1941 <\/option>\n <option value=\"1940\"> 1940 <\/option>\n <option value=\"1939\"> 1939 <\/option>\n <option value=\"1938\"> 1938 <\/option>\n <option value=\"1937\"> 1937 <\/option>\n <option value=\"1936\"> 1936 <\/option>\n <option value=\"1935\"> 1935 <\/option>\n <option value=\"1934\"> 1934 <\/option>\n <option value=\"1933\"> 1933 <\/option>\n <option value=\"1932\"> 1932 <\/option>\n <option value=\"1931\"> 1931 <\/option>\n <option value=\"1930\"> 1930 <\/option>\n <option value=\"1929\"> 1929 <\/option>\n <option value=\"1928\"> 1928 <\/option>\n <option value=\"1927\"> 1927 <\/option>\n <option value=\"1926\"> 1926 <\/option>\n <option value=\"1925\"> 1925 <\/option>\n <option value=\"1924\"> 1924 <\/option>\n <option value=\"1923\"> 1923 <\/option>\n <option value=\"1922\"> 1922 <\/option>\n <option value=\"1921\"> 1921 <\/option>\n <option value=\"1920\"> 1920 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_82_year\" id=\"sublabel_year\"> Year <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_43\">\n <label class=\"form-label-left\" id=\"label_43\" for=\"input_43\"> Which insurance company are you insured with: <\/label>\n <div id=\"cid_43\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_43\" name=\"q43_whichInsurance43\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_44\">\n <label class=\"form-label-left\" id=\"label_44\" for=\"input_44\"> CURRENT MEDICATIONS AND\/OR RECENT TREATMENTS: <\/label>\n <div id=\"cid_44\" class=\"form-input\">\n <textarea id=\"input_44\" class=\"form-textarea\" name=\"q44_currentMedications44\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_45\">\n <div id=\"cid_45\" class=\"form-input-wide\">\n <div id=\"text_45\" class=\"form-html\">\n Please note that pets requiring repeat prescriptions will need to be assessed every four months for which there is a prescription evaluation fee.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_46\">\n <label class=\"form-label-left\" id=\"label_46\" for=\"input_46\"> Where did you get your pets from: <\/label>\n <div id=\"cid_46\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_46\" name=\"q46_whereDid46\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_60\">\n <label class=\"form-label-left\" id=\"label_60\" for=\"input_60\"> Previous Vets (if relevant): <\/label>\n <div id=\"cid_60\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_60\" name=\"q60_previousVets\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_48\">\n <label class=\"form-label-left\" id=\"label_48\" for=\"input_48\"> Reason for visit: <\/label>\n <div id=\"cid_48\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_48\" name=\"q48_reasonFor\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_53\">\n <label class=\"form-label-left\" id=\"label_53\" for=\"input_53\">\n Please enter the code and press Submit:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_53\" class=\"form-input\">\n <div class=\"form-captcha\">\n <label for=\"input_53\"> <img alt=\"Captcha - Reload if it's not displayed\" id=\"input_53_captcha\" class=\"form-captcha-image\" style=\"background:url(http:\/\/www.jotform.com\/images\/loader-big.gif) no-repeat center;\" src=\"http:\/\/www.jotform.com\/images\/blank.gif\" width=\"150\" height=\"41\" \/> <\/label>\n <div style=\"white-space:nowrap;\">\n <input type=\"text\" id=\"input_53\" class=\"form-textbox validate[required]\" name=\"captcha\" style=\"width:130px;\" \/>\n <img src=\"http:\/\/www.jotform.com\/images\/reload.png\" alt=\"Reload\" align=\"absmiddle\" style=\"cursor:pointer\" onclick=\"JotForm.reloadCaptcha('input_53');\" \/>\n <input type=\"hidden\" name=\"captcha_id\" id=\"input_53_captcha_id\" value=\"0\">\n <\/div>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_7\">\n <div id=\"cid_7\" class=\"form-input-wide\">\n <div style=\"margin-left:156px\" class=\"form-buttons-wrapper\">\n <button id=\"input_7\" type=\"submit\" class=\"form-submit-button\">\n Submit\n <\/button>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_70\">\n <div id=\"cid_70\" class=\"form-input-wide\">\n <div id=\"text_70\" class=\"form-html\">\n TERMS AND CONDITIONS OF BUSINESS\n <br>\n <br><span style=\"font-style: italic;\">All fees MUST be paid for at the time of consultation or discharge after treatment. Payment can be by Cash Delta, Switch, Visa or Access. We operate on our standard terms and conditions of business. If you wish to see a copy, please ask the practice manager.<\/span>\n <br style=\"font-style: italic;\"><span style=\"font-style: italic;\">Please do not send children under 16 yrs with pets to the Centre unless by prior arrangement with the Veterinary Surgeon. Please do not send third parties with pets, as treatments can be complicated by lack of accurate history.<\/span>\n <br style=\"font-style: italic;\"><span style=\"font-style: italic;\">For safety reasons, please ensure that your pet is adequately restrained whilst on the premises \u2013 dogs should be on a lead and cats, rabbits, birds etc in a suitable carrier.<\/span>\n <br>\n <br>\n Thank you\n <\/div>\n <\/div>\n <\/li>\n <li style=\"display:none\">\n Should be Empty:\n <input type=\"text\" name=\"website\" value=\"\" \/>\n <\/li>\n <\/ul>\n <\/div>\n <input type=\"hidden\" id=\"simple_spc\" name=\"simple_spc\" value=\"10733219336\" \/>\n <script type=\"text\/javascript\">\n document.getElementById(\"si\" + \"mple\" + \"_spc\").value = \"10733219336-10733219336\";\n <\/script>\n<\/form><\/body>\n<\/html>\n");