/*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 i10813415584 = new FrameBuilder("10813415584", 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:520px;\n background:white;\n color:black !important;\n font-family:Arial;\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.setCalendar(\"13\");\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_10813415584\" id=\"10813415584\" accept-charset=\"utf-8\">\n <input type=\"hidden\" name=\"formID\" value=\"10813415584\" \/>\n <div class=\"form-all\">\n <ul class=\"form-section\">\n <li class=\"form-line\" id=\"id_2\">\n <label class=\"form-label-left\" id=\"label_2\" for=\"input_2\">\n Patient's Age<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_2\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_2\" name=\"q2_patientsAge\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_12\">\n <label class=\"form-label-left\" id=\"label_12\" for=\"input_12\">\n Patient's Sex<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_12\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_12_0\" name=\"q12_patientsSex\" value=\"Male\" \/>\n <label for=\"input_12_0\"> Male <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_12_1\" name=\"q12_patientsSex\" value=\"Female\" \/>\n <label for=\"input_12_1\"> Female <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_13\">\n <label class=\"form-label-left\" id=\"label_13\" for=\"input_13\">\n Date of Visit<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_13\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" id=\"month_13\" name=\"q13_dateOf[month]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"02\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"month_13\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" id=\"day_13\" name=\"q13_dateOf[day]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"10\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"day_13\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" id=\"year_13\" name=\"q13_dateOf[year]\" type=\"text\" size=\"4\" maxlength=\"4\" value=\"2012\" \/>\n <label class=\"form-sub-label\" for=\"year_13\" id=\"sublabel_year\"> Year <\/label><\/span><span class=\"form-sub-label-container\"><div id=\"at_13\">\n at\n <\/div>\n <label class=\"form-sub-label\" for=\"at_13\"> <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" id=\"hour_13\" name=\"q13_dateOf[hour]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"01\" \/><span class=\"date-separate\"> \/<\/span>\n <label class=\"form-sub-label\" for=\"hour_13\" id=\"sublabel_hour\"> Hour <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" id=\"min_13\" name=\"q13_dateOf[min]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"51\" \/>\n <label class=\"form-sub-label\" for=\"min_13\" id=\"sublabel_minutes\"> Minutes <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown validate[required]\" id=\"ampm_13\" name=\"q13_dateOf[ampm]\">\n <option value=\"AM\"> AM <\/option>\n <option value=\"PM\"> PM <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"ampm_13\"> <\/label><\/span><span class=\"form-sub-label-container\"><img alt=\"Pick a Date\" id=\"input_13_pick\" src=\"http:\/\/www.jotform.com\/images\/calendar.png\" align=\"absmiddle\" \/>\n <label class=\"form-sub-label\" for=\"input_13_pick\"> <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_41\">\n <label class=\"form-label-left\" id=\"label_41\" for=\"input_41\">\n Name of Physician that took care of you:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_41\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_41\" name=\"q41_nameOf\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_14\">\n <label class=\"form-label-left\" id=\"label_14\" for=\"input_14\">\n Time of Day you arrived at Guardian Urgent Care:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_14\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_14_0\" name=\"q14_timeOf\" value=\"8 a.m. - 12 p.m.\" \/>\n <label for=\"input_14_0\"> 8 a.m. - 12 p.m. <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_14_1\" name=\"q14_timeOf\" value=\"12 p.m. - 4 p. m.\" \/>\n <label for=\"input_14_1\"> 12 p.m. - 4 p. m. <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_14_2\" name=\"q14_timeOf\" value=\"4 p.m. - 8 p.m.\" \/>\n <label for=\"input_14_2\"> 4 p.m. - 8 p.m. <\/label><\/span><span class=\"clearfix\"><\/span>\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\">\n Why did you Visit Guardian Urgent Care?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_16\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_16_0\" name=\"q16_whyDid\" value=\"Illness\" \/>\n <label for=\"input_16_0\"> Illness <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_16_1\" name=\"q16_whyDid\" value=\"Injury\" \/>\n <label for=\"input_16_1\"> Injury <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_16_2\" name=\"q16_whyDid\" value=\"x-ray\" \/>\n <label for=\"input_16_2\"> x-ray <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_16_3\" name=\"q16_whyDid\" value=\"drug screen\" \/>\n <label for=\"input_16_3\"> drug screen <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_16_4\" name=\"q16_whyDid\" value=\"other lab test\" \/>\n <label for=\"input_16_4\"> other lab test <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_16_5\" name=\"q16_whyDid\" value=\"physical (work\/school\/wellness)\" \/>\n <label for=\"input_16_5\"> physical (work\/school\/wellness) <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_17\">\n <label class=\"form-label-left\" id=\"label_17\" for=\"input_17\"> If you answered Injury to the previous question was it work related? <\/label>\n <div id=\"cid_17\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_17_0\" name=\"q17_ifYou\" value=\"Yes\" \/>\n <label for=\"input_17_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_17_1\" name=\"q17_ifYou\" value=\"No\" \/>\n <label for=\"input_17_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_18\">\n <label class=\"form-label-left\" id=\"label_18\" for=\"input_18\">\n How did you hear about Guardian Urgent Care?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_18\" class=\"form-input\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_18\" name=\"q18_howDid\">\n <option> <\/option>\n <option value=\"Advertisement\"> Advertisement <\/option>\n <option value=\"Internet\/Website\"> Internet\/Website <\/option>\n <option value=\"Drove by the Building and noticed the sign\"> Drove by the Building and noticed the sign <\/option>\n <option value=\"Insurance provider directory\"> Insurance provider directory <\/option>\n <option value=\"Recommendation by family or friend\"> Recommendation by family or friend <\/option>\n <option value=\"Recommendation by another medical provider. \"> Recommendation by another medical provider. <\/option>\n <option value=\"Recommendation by my employer. \"> Recommendation by my employer. <\/option>\n <option value=\"Other\"> Other <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_19\">\n <label class=\"form-label-left\" id=\"label_19\" for=\"input_19\"> If you answered advertisement to the previous question, where did you see our ad? <\/label>\n <div id=\"cid_19\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_19\" name=\"q19_ifYou19\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_21\">\n <label class=\"form-label-left\" id=\"label_21\" for=\"input_21\"> If you answered employer to the previous question, who is your employer? <\/label>\n <div id=\"cid_21\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_21\" name=\"q21_ifYou21\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_20\">\n <label class=\"form-label-left\" id=\"label_20\" for=\"input_20\"> If you answered recommended by another medical provider, what is the name of the provider or Medical Practice? <\/label>\n <div id=\"cid_20\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_20\" name=\"q20_ifYou20\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_23\">\n <div id=\"cid_23\" class=\"form-input-wide\">\n <div id=\"text_23\" class=\"form-html\">\n Please rate Guardian Urgent Care in the following areas:\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_22\">\n <label class=\"form-label-left\" id=\"label_22\" for=\"input_22\">\n Hours of Operation<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_22\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_22_0\" name=\"q22_hoursOf\" value=\"Excellent\" \/>\n <label for=\"input_22_0\"> Excellent <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_22_1\" name=\"q22_hoursOf\" value=\"Very Good\" \/>\n <label for=\"input_22_1\"> Very Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_22_2\" name=\"q22_hoursOf\" value=\"Good\" \/>\n <label for=\"input_22_2\"> Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_22_3\" name=\"q22_hoursOf\" value=\"Fair\" \/>\n <label for=\"input_22_3\"> Fair <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_22_4\" name=\"q22_hoursOf\" value=\"Poor\" \/>\n <label for=\"input_22_4\"> Poor <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_22_5\" name=\"q22_hoursOf\" value=\"Does Not Apply\" \/>\n <label for=\"input_22_5\"> Does Not Apply <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_24\">\n <label class=\"form-label-left\" id=\"label_24\" for=\"input_24\">\n Services Offered<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_24\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_24_0\" name=\"q24_servicesOffered\" value=\"Excellent\" \/>\n <label for=\"input_24_0\"> Excellent <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_24_1\" name=\"q24_servicesOffered\" value=\"Very Good\" \/>\n <label for=\"input_24_1\"> Very Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_24_2\" name=\"q24_servicesOffered\" value=\"Good\" \/>\n <label for=\"input_24_2\"> Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_24_3\" name=\"q24_servicesOffered\" value=\"Fair\" \/>\n <label for=\"input_24_3\"> Fair <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_24_4\" name=\"q24_servicesOffered\" value=\"Poor\" \/>\n <label for=\"input_24_4\"> Poor <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_24_5\" name=\"q24_servicesOffered\" value=\"Does Not Apply\" \/>\n <label for=\"input_24_5\"> Does Not Apply <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_25\">\n <label class=\"form-label-left\" id=\"label_25\" for=\"input_25\">\n Convenience of Location<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_25\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_25_0\" name=\"q25_convenienceOf\" value=\"Excellent\" \/>\n <label for=\"input_25_0\"> Excellent <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_25_1\" name=\"q25_convenienceOf\" value=\"Very Good\" \/>\n <label for=\"input_25_1\"> Very Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_25_2\" name=\"q25_convenienceOf\" value=\"Good\" \/>\n <label for=\"input_25_2\"> Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_25_3\" name=\"q25_convenienceOf\" value=\"Fair\" \/>\n <label for=\"input_25_3\"> Fair <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_25_4\" name=\"q25_convenienceOf\" value=\"Poor\" \/>\n <label for=\"input_25_4\"> Poor <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_25_5\" name=\"q25_convenienceOf\" value=\"Does Not Apply\" \/>\n <label for=\"input_25_5\"> Does Not Apply <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_26\">\n <label class=\"form-label-left\" id=\"label_26\" for=\"input_26\">\n Front Desk Staff was Friendly and Knowledgeable<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_26\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_26_0\" name=\"q26_frontDesk\" value=\"Excellent\" \/>\n <label for=\"input_26_0\"> Excellent <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_26_1\" name=\"q26_frontDesk\" value=\"Very Good\" \/>\n <label for=\"input_26_1\"> Very Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_26_2\" name=\"q26_frontDesk\" value=\"Good\" \/>\n <label for=\"input_26_2\"> Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_26_3\" name=\"q26_frontDesk\" value=\"Fair\" \/>\n <label for=\"input_26_3\"> Fair <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_26_4\" name=\"q26_frontDesk\" value=\"Poor\" \/>\n <label for=\"input_26_4\"> Poor <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_26_5\" name=\"q26_frontDesk\" value=\"Does Not Apply\" \/>\n <label for=\"input_26_5\"> Does Not Apply <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_45\">\n <label class=\"form-label-left\" id=\"label_45\" for=\"input_45\"> Click to edit <\/label>\n <div id=\"cid_45\" class=\"form-input\">\n <textarea id=\"input_45\" class=\"form-textarea\" name=\"q45_clickTo\" cols=\"40\" rows=\"6\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_27\">\n <label class=\"form-label-left\" id=\"label_27\" for=\"input_27\">\n Time spent in Waiting Room<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_27\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_27_0\" name=\"q27_timeSpent\" value=\"Excellent\" \/>\n <label for=\"input_27_0\"> Excellent <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_27_1\" name=\"q27_timeSpent\" value=\"Very Good\" \/>\n <label for=\"input_27_1\"> Very Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_27_2\" name=\"q27_timeSpent\" value=\"Good\" \/>\n <label for=\"input_27_2\"> Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_27_3\" name=\"q27_timeSpent\" value=\"Fair\" \/>\n <label for=\"input_27_3\"> Fair <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_27_4\" name=\"q27_timeSpent\" value=\"Poor\" \/>\n <label for=\"input_27_4\"> Poor <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_27_5\" name=\"q27_timeSpent\" value=\"Does Not Apply\" \/>\n <label for=\"input_27_5\"> Does Not Apply <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_28\">\n <label class=\"form-label-left\" id=\"label_28\" for=\"input_28\">\n Time spent in Exam Room<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_28\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_28_0\" name=\"q28_timeSpent28\" value=\"Excellent\" \/>\n <label for=\"input_28_0\"> Excellent <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_28_1\" name=\"q28_timeSpent28\" value=\"Very Good\" \/>\n <label for=\"input_28_1\"> Very Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_28_2\" name=\"q28_timeSpent28\" value=\"Good\" \/>\n <label for=\"input_28_2\"> Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_28_3\" name=\"q28_timeSpent28\" value=\"Fair\" \/>\n <label for=\"input_28_3\"> Fair <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_28_4\" name=\"q28_timeSpent28\" value=\"Poor\" \/>\n <label for=\"input_28_4\"> Poor <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_28_5\" name=\"q28_timeSpent28\" value=\"Does Not Apply\" \/>\n <label for=\"input_28_5\"> Does Not Apply <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_29\">\n <label class=\"form-label-left\" id=\"label_29\" for=\"input_29\">\n Medical Staff was friendly and knowledgeable<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_29\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_29_0\" name=\"q29_medicalStaff\" value=\"Excellent\" \/>\n <label for=\"input_29_0\"> Excellent <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_29_1\" name=\"q29_medicalStaff\" value=\"Very Good\" \/>\n <label for=\"input_29_1\"> Very Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_29_2\" name=\"q29_medicalStaff\" value=\"Good\" \/>\n <label for=\"input_29_2\"> Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_29_3\" name=\"q29_medicalStaff\" value=\"Fair\" \/>\n <label for=\"input_29_3\"> Fair <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_29_4\" name=\"q29_medicalStaff\" value=\"Poor\" \/>\n <label for=\"input_29_4\"> Poor <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_29_5\" name=\"q29_medicalStaff\" value=\"Does Not Apply\" \/>\n <label for=\"input_29_5\"> Does Not Apply <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_30\">\n <label class=\"form-label-left\" id=\"label_30\" for=\"input_30\">\n Physician listened to you and answered all questions<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_30\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_30_0\" name=\"q30_physicianListened\" value=\"Excellent\" \/>\n <label for=\"input_30_0\"> Excellent <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_30_1\" name=\"q30_physicianListened\" value=\"Very Good\" \/>\n <label for=\"input_30_1\"> Very Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_30_2\" name=\"q30_physicianListened\" value=\"Good\" \/>\n <label for=\"input_30_2\"> Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_30_3\" name=\"q30_physicianListened\" value=\"Fair\" \/>\n <label for=\"input_30_3\"> Fair <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_30_4\" name=\"q30_physicianListened\" value=\"Poor\" \/>\n <label for=\"input_30_4\"> Poor <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_30_5\" name=\"q30_physicianListened\" value=\"Does Not Apply\" \/>\n <label for=\"input_30_5\"> Does Not Apply <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_31\">\n <label class=\"form-label-left\" id=\"label_31\" for=\"input_31\">\n Level of Treatment by the Physician<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_31\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_31_0\" name=\"q31_levelOf\" value=\"Excellent\" \/>\n <label for=\"input_31_0\"> Excellent <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_31_1\" name=\"q31_levelOf\" value=\"Very Good\" \/>\n <label for=\"input_31_1\"> Very Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_31_2\" name=\"q31_levelOf\" value=\"Good\" \/>\n <label for=\"input_31_2\"> Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_31_3\" name=\"q31_levelOf\" value=\"Fair\" \/>\n <label for=\"input_31_3\"> Fair <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_31_4\" name=\"q31_levelOf\" value=\"Poor\" \/>\n <label for=\"input_31_4\"> Poor <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_31_5\" name=\"q31_levelOf\" value=\"Does Not Apply\" \/>\n <label for=\"input_31_5\"> Does Not Apply <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_32\">\n <label class=\"form-label-left\" id=\"label_32\" for=\"input_32\">\n Time spent waiting for Laboratory Samples<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_32\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_32_0\" name=\"q32_timeSpent32\" value=\"Excellent\" \/>\n <label for=\"input_32_0\"> Excellent <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_32_1\" name=\"q32_timeSpent32\" value=\"Very Good\" \/>\n <label for=\"input_32_1\"> Very Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_32_2\" name=\"q32_timeSpent32\" value=\"Good\" \/>\n <label for=\"input_32_2\"> Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_32_3\" name=\"q32_timeSpent32\" value=\"Fair\" \/>\n <label for=\"input_32_3\"> Fair <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_32_4\" name=\"q32_timeSpent32\" value=\"Poor\" \/>\n <label for=\"input_32_4\"> Poor <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_32_5\" name=\"q32_timeSpent32\" value=\"Does Not Apply\" \/>\n <label for=\"input_32_5\"> Does Not Apply <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_33\">\n <label class=\"form-label-left\" id=\"label_33\" for=\"input_33\">\n Pricing for Services<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_33\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_33_0\" name=\"q33_pricingFor\" value=\"Excellent\" \/>\n <label for=\"input_33_0\"> Excellent <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_33_1\" name=\"q33_pricingFor\" value=\"Very Good\" \/>\n <label for=\"input_33_1\"> Very Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_33_2\" name=\"q33_pricingFor\" value=\"Good\" \/>\n <label for=\"input_33_2\"> Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_33_3\" name=\"q33_pricingFor\" value=\"Fair\" \/>\n <label for=\"input_33_3\"> Fair <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_33_4\" name=\"q33_pricingFor\" value=\"Poor\" \/>\n <label for=\"input_33_4\"> Poor <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_33_5\" name=\"q33_pricingFor\" value=\"Does Not Apply\" \/>\n <label for=\"input_33_5\"> Does Not Apply <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_34\">\n <label class=\"form-label-left\" id=\"label_34\" for=\"input_34\">\n Charges were explained<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_34\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_34_0\" name=\"q34_chargesWere\" value=\"Excellent\" \/>\n <label for=\"input_34_0\"> Excellent <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_34_1\" name=\"q34_chargesWere\" value=\"Very Good\" \/>\n <label for=\"input_34_1\"> Very Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_34_2\" name=\"q34_chargesWere\" value=\"Good\" \/>\n <label for=\"input_34_2\"> Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_34_3\" name=\"q34_chargesWere\" value=\"Fair\" \/>\n <label for=\"input_34_3\"> Fair <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_34_4\" name=\"q34_chargesWere\" value=\"Poor\" \/>\n <label for=\"input_34_4\"> Poor <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_34_5\" name=\"q34_chargesWere\" value=\"Does Not Apply\" \/>\n <label for=\"input_34_5\"> Does Not Apply <\/label><\/span><span class=\"clearfix\"><\/span>\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\">\n Overall Cleanliness of the Facility<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_35\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_35_0\" name=\"q35_overallCleanliness\" value=\"Excellent\" \/>\n <label for=\"input_35_0\"> Excellent <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_35_1\" name=\"q35_overallCleanliness\" value=\"Very Good\" \/>\n <label for=\"input_35_1\"> Very Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_35_2\" name=\"q35_overallCleanliness\" value=\"Good\" \/>\n <label for=\"input_35_2\"> Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_35_3\" name=\"q35_overallCleanliness\" value=\"Fair\" \/>\n <label for=\"input_35_3\"> Fair <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_35_4\" name=\"q35_overallCleanliness\" value=\"Poor\" \/>\n <label for=\"input_35_4\"> Poor <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_35_5\" name=\"q35_overallCleanliness\" value=\"Does Not Apply\" \/>\n <label for=\"input_35_5\"> Does Not Apply <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_36\">\n <label class=\"form-label-left\" id=\"label_36\" for=\"input_36\">\n Overall Comfort during your visit<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_36\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_36_0\" name=\"q36_overallComfort\" value=\"Excellent\" \/>\n <label for=\"input_36_0\"> Excellent <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_36_1\" name=\"q36_overallComfort\" value=\"Very Good\" \/>\n <label for=\"input_36_1\"> Very Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_36_2\" name=\"q36_overallComfort\" value=\"Good\" \/>\n <label for=\"input_36_2\"> Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_36_3\" name=\"q36_overallComfort\" value=\"Fair\" \/>\n <label for=\"input_36_3\"> Fair <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_36_4\" name=\"q36_overallComfort\" value=\"Poor\" \/>\n <label for=\"input_36_4\"> Poor <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_36_5\" name=\"q36_overallComfort\" value=\"Does Not Apply\" \/>\n <label for=\"input_36_5\"> Does Not Apply <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_37\">\n <label class=\"form-label-left\" id=\"label_37\" for=\"input_37\">\n Overall Quality of Care<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_37\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_37_0\" name=\"q37_overallQuality\" value=\"Excellent\" \/>\n <label for=\"input_37_0\"> Excellent <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_37_1\" name=\"q37_overallQuality\" value=\"Very Good\" \/>\n <label for=\"input_37_1\"> Very Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_37_2\" name=\"q37_overallQuality\" value=\"Good\" \/>\n <label for=\"input_37_2\"> Good <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_37_3\" name=\"q37_overallQuality\" value=\"Fair\" \/>\n <label for=\"input_37_3\"> Fair <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_37_4\" name=\"q37_overallQuality\" value=\"Poor\" \/>\n <label for=\"input_37_4\"> Poor <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_37_5\" name=\"q37_overallQuality\" value=\"Does Not Apply\" \/>\n <label for=\"input_37_5\"> Does Not Apply <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_38\">\n <label class=\"form-label-left\" id=\"label_38\" for=\"input_38\">\n Would you recommend Guardian Urgent Care to Others?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_38\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_38_0\" name=\"q38_wouldYou\" value=\"Yes\" \/>\n <label for=\"input_38_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_38_1\" name=\"q38_wouldYou\" value=\"Maybe\" \/>\n <label for=\"input_38_1\"> Maybe <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_38_2\" name=\"q38_wouldYou\" value=\"No\" \/>\n <label for=\"input_38_2\"> No <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_38_3\" name=\"q38_wouldYou\" value=\"Never\" \/>\n <label for=\"input_38_3\"> Never <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_39\">\n <label class=\"form-label-left\" id=\"label_39\" for=\"input_39\">\n Why did you choose Guardian Urgent Care over other Hospitals\/Medical Facilities?:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_39\" class=\"form-input\">\n <textarea id=\"input_39\" class=\"form-textarea validate[required]\" name=\"q39_whyDid39\" cols=\"30\" rows=\"5\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_9\">\n <label class=\"form-label-left\" id=\"label_9\" for=\"input_9\">\n What suggestions and\/or comments do you have for Guardian Urgent Care so that we may strive for excellence:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_9\" class=\"form-input\">\n <textarea id=\"input_9\" class=\"form-textarea validate[required]\" name=\"q9_whatSuggestions\" cols=\"30\" rows=\"5\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_44\">\n <label class=\"form-label-left\" id=\"label_44\" for=\"input_44\"> May we use your comments on our website, flyer, or any other publication produced by Guardian Urgent Care? <\/label>\n <div id=\"cid_44\" 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_44_0\" name=\"q44_mayWe[]\" value=\"Yes\" \/>\n <label for=\"input_44_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_44_1\" name=\"q44_mayWe[]\" value=\"No\" \/>\n <label for=\"input_44_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_42\">\n <label class=\"form-label-left\" id=\"label_42\" for=\"input_42\"> Email Address: <\/label>\n <div id=\"cid_42\" class=\"form-input\">\n <textarea id=\"input_42\" class=\"form-textarea\" name=\"q42_emailAddress\" cols=\"30\" rows=\"1\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_1\">\n <div id=\"cid_1\" class=\"form-input-wide\">\n <div style=\"margin-left:156px\" class=\"form-buttons-wrapper\">\n <button id=\"input_1\" type=\"submit\" class=\"form-submit-button\">\n Submit\n <\/button>\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=\"10813415584\" \/>\n <script type=\"text\/javascript\">\n document.getElementById(\"si\" + \"mple\" + \"_spc\").value = \"10813415584-10813415584\";\n <\/script>\n<\/form><\/body>\n<\/html>\n");