{"id":3287,"date":"2026-04-05T12:54:43","date_gmt":"2026-04-05T12:54:43","guid":{"rendered":"http:\/\/64.23.228.134\/?page_id=3287"},"modified":"2026-04-19T14:58:07","modified_gmt":"2026-04-19T14:58:07","slug":"intake-form","status":"publish","type":"page","link":"https:\/\/myvidamed.com\/en\/intake-form\/","title":{"rendered":"Intake Form"},"content":{"rendered":"<div id=\"glp-form\">\n<form id=\"glp-multistep\" class=\"glp-multistep\" method=\"post\" enctype=\"multipart\/form-data\" novalidate>\n<input type=\"hidden\" name=\"action\" value=\"save_glp_form\" \/> \n<input type=\"hidden\" name=\"stripe-email-field\" class=\"stripe-email-field input\" \/>\n\n<!-- STEP 1 \u2014 Contact Information -->\n<div class=\"glp-step active\" data-step=\"1\">\n  <h2 class=\"mb-8\">Contact Information<\/h2>\n<div class=\"sub-heading\">\n\tThis form takes approximately 2\u20133 minutes to complete.<\/div>\n\n  <div class=\"col-6 mb-3 relative\">\n    <label>First Name*<\/label>\n    <input name=\"name\" required autocomplete=\"name\">\n  <\/div>\n   <div class=\"col-6 mb-3 relative\">\n    <label>Last Name*<\/label>\n    <input type=\"text\" name=\"last_name\" required autocomplete=\"off\">\n  <\/div>\n\n  <div class=\"col-6 mb-3 relative\">\n    <label>Phone*<\/label>\n    <input name=\"phone\" required autocomplete=\"off\" class=\"us-phone\"\n       value=\"+1 (___) ___ - ____\" mask=\"+1 (___) ___ - ____\" placeholder=\"+1 (___) ___ - ____\" >\n  <\/div>\n\n  <div class=\"col-6 mb-3 relative\">\n    <label>Email*<\/label>\n    <input type=\"email\" name=\"email\" required autocomplete=\"email\">\n  <\/div>\n\n  <div class=\"col-6 mb-3 relative\">\n    <label>Zip Code*<\/label>\n    <input name=\"zip\" required autocomplete=\"postal-code\">\n  <\/div>\n\n  <div class=\"col-6 mb-3 relative recaptcha\">\n    <div class=\"g-recaptcha\" data-sitekey=\"6LeiRP0sAAAAAPPlFhM0ftyElJfgfJhmLqnocr76\"><\/div>\n  <\/div>\n\n  <div class=\"col-6 mb-3 relative\">\n    <button type=\"button\" class=\"save_first_setup_data next\">Continue<\/button>\n  <\/div>\n<\/div>\n\n\n<!-- STEPS 2\u20133 \u2014 Dynamic questions 5 & 6 -->\n<div class=\"glp-step\" data-step=\"2\">\n\n    \n    <div class=\"glp-question-block  wrap_question_5\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        What are your weight loss goals?                    <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"Lose 1-20lbs for good\"\n                            >\n                                    Lose 1-20lbs for good        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"Lose 21-50lbs for good\"\n                            >\n                                    Lose 21-50lbs for good        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"Lose over 50lbs for good\"\n                            >\n                                    Lose over 50lbs for good        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"Maintain my healthy weight\"\n                            >\n                                    Maintain my healthy weight        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"None of the above\"\n                            >\n                                    None of the above        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"Other\"\n                            >\n                                    Other        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"next\">Continue<\/button>\n    <\/div>\n\n<\/div>\n<div class=\"glp-step\" data-step=\"3\">\n\n    \n    <div class=\"glp-question-block  wrap_question_6\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        What weight loss initiatives have you tried in the past? Select all that apply             <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-options\">\n                \n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_6[]\"\n                            value=\"Exercise, Dieting\"\n                            required                        >\n                        Exercise, Dieting                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_6[]\"\n                            value=\"Weight-loss Supplements\"\n                            required                        >\n                        Weight-loss Supplements                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_6[]\"\n                            value=\"Intermittent Fasting\"\n                            required                        >\n                        Intermittent Fasting                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_6[]\"\n                            value=\"None of the Above\"\n                            required                        >\n                        None of the Above                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_6[]\"\n                            value=\"Other\"\n                            required                        >\n                        Other                    <\/label>\n                            <\/div>\n\n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"next\">Continue<\/button>\n    <\/div>\n\n<\/div>\n\n\n<!-- STEP 4 \u2014 Treatment Options -->\n<div class=\"glp-step\" data-step=\"4\">\n\n  <h2>Treatment Options<\/h2>\n\n  \n    <div class=\"glp-question-block  wrap_question_7\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Which treatment option are you most interested in?\n\n            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Select Box -->\n                    <div class=\"glp-field\">\n                        <select \n                            id =\"question_7\"\n                            name=\"question_7\" \n                            class=\"glp-select\"\n                            required                        >\n\n                            <option value=\"\"> Select a medication<\/option>\n\n                                                        <option value=\"Semaglutide - Weekly INJECTION \u2013 1 month: $297\/month\">\n                                Semaglutide - Weekly INJECTION \u2013 Monthly Plan: $297\/month                                    \n                            <\/option>\n                                                        <option value=\"Semaglutide - Weekly INJECTION \u2013 3-month plan: $197\/month ($591 total) \u2013 Save $300!\">\n                                Semaglutide - Weekly INJECTION \u2013 3-month plan: $197\/month ($591 total) \u2013 Save $300!                                    \n                            <\/option>\n                                                        <option value=\"Semaglutide - Daily TABLET \u2013 1 month: $297\/month\">\n                                Semaglutide - Daily TABLET \u2013 Monthly Plan: $297\/month                                    \n                            <\/option>\n                                                        <option value=\"Semaglutide - Daily TABLET \u2013 3-month plan: $197\/month ($591 total) \u2013 Save $300!\">\n                                Semaglutide - Daily TABLET \u2013 3-month plan: $197\/month ($591 total) \u2013 Save $300!                                    \n                            <\/option>\n                                                        <option value=\" Tirzepatide - Weekly INJECTION \u2013 1 month: $397\/month\">\n                                 Tirzepatide - Weekly INJECTION \u2013 Monthly Plan: $397\/month                                    \n                            <\/option>\n                                                        <option value=\"Tirzepatide - Weekly INJECTION \u2013 3-month plan: $297\/month ($891 total) \u2013 Save $300!\">\n                                Tirzepatide - Weekly INJECTION \u2013 3-month plan: $297\/month ($891 total) \u2013 Save $300!                                    \n                            <\/option>\n                                                        <option value=\" Tirzepatide - Daily TABLET \u2013 1 month: $397\/month\">\n                                 Tirzepatide - Daily TABLET \u2013 Monthly Plan: $397\/month                                    \n                            <\/option>\n                                                        <option value=\"Tirzepatide - Daily TABLET \u2013 3-month plan: $297\/month ($891 total) \u2013 Save $300!\">\n                                Tirzepatide - Daily TABLET \u2013 3-month plan: $297\/month ($891 total) \u2013 Save $300!                                    \n                            <\/option>\n                            \n                        <\/select>\n                    <\/div>\n\n                \n        \n    <\/div>\n\n    \n <p class=\"glp-note mb-5\">\n    Note: All options include personalized compounded medication as prescribed by your doctor, all necessary supplies, ongoing medical support, and free nationwide shipping.  <\/p> \n\n  <input type=\"hidden\" name=\"product_id\" id=\"product_id\">\n\n  <div class=\"glp-info-box small-dot-list\">\n    <p>Important:<\/p>\n    <ul>\n      <li>You will only be charged if the doctor approves the medication. If you do not qualify, no charge will be made.<\/li>\n      <li>Vidamed does not auto-charge. Your card is securely stored in the portal so you don't have to re-enter it<\/li>\n      <li>For Monthly plans: you're charged the first month price. Subsequent months are charged at regular price only after your approval.<\/li>\n      <li>For 3-month plans: it's a single upfront payment of the total amount.<\/li>\n      <li>You will always receive text\/email reminders to approve future refills.<\/li>\n    <\/ul>\n  <\/div>\n\n  <div class=\"glp-navigation\">\n    <button type=\"button\" class=\"prev\">Back<\/button>\n    <button type=\"button\" class=\"next\">Continue<\/button>\n  <\/div>\n\n<\/div>\n\n\n<!-- STEP 5 \u2014 Physical Measurements -->\n<div class=\"glp-step\" data-step=\"5\">\n\n  <h2>Physical Measurements<\/h2>\n\n  <div class=\"glp-question-block\">\n\n    <p class=\"glp-question mb-5\">\n      Please provide your physical measurements and demographic information      <span class=\"required\">*<\/span>\n    <\/p>\n\n    <div class=\"glp-row\">\n\n      <!-- Height FT -->\n      <div class=\"glp-field\">\n        <label>Height (ft)<\/label>\n        <input type=\"number\" name=\"height_ft\" min=\"1\" max=\"8\" required>\n        <small class=\"glp-help-text\">Please enter a number greater than or equal to 1<\/small>\n        <small class=\"glp-error-text\" data-error=\"height_ft\"><\/small>\n      <\/div>\n\n      <!-- Height IN -->\n      <div class=\"glp-field\">\n        <label>Height (in)<\/label>\n        <input type=\"number\" name=\"height_in\" min=\"0\" max=\"11\" required>\n        <small class=\"glp-help-text\">Please enter a number from 0 to 11<\/small>\n        <small class=\"glp-error-text\" data-error=\"height_in\"><\/small>\n      <\/div>\n\n    <\/div>\n\n    <!-- Weight -->\n    <div class=\"glp-field\">\n      <label>Weight (lbs)<\/label>\n      <input type=\"number\" name=\"weight\" id=\"weight\" min=\"50\" max=\"700\" required>\n      <small class=\"glp-error-text\" data-error=\"weight\"><\/small>\n    <\/div>\n\n    <!-- BMI -->\n    <div class=\"glp-field\">\n      <label>BMI<\/label>\n      <input type=\"text\" name=\"bmi\" id=\"bmi\" readonly>\n    <\/div>\n\n    <!-- Gender -->\n    <div class=\"glp-field\" id=\"glp-field-gender\">\n      <label>Gender<\/label>\n      <div class=\"glp-options\">\n        <label class=\"glp-option\">\n          <input type=\"radio\" name=\"gender\" value=\"male\" required>\n          Male        <\/label>\n        <label class=\"glp-option\">\n          <input type=\"radio\" name=\"gender\" value=\"female\">\n          Female        <\/label>\n      <\/div>\n      <small class=\"glp-error-text\" data-error=\"gender\"><\/small>\n    <\/div>\n\n    <!-- DOB -->\n    <div class=\"glp-field\">\n      <label>Date of Birth<\/label>\n      <input type=\"text\" name=\"dob\" id=\"dob\" required>\n      <small class=\"glp-error-text\" data-error=\"dob\"><\/small>\n    <\/div>\n\n  <\/div>\n\n  <div class=\"glp-navigation\">\n    <button type=\"button\" class=\"prev\">Back<\/button>\n    <button type=\"button\" class=\"next\">Continue<\/button>\n  <\/div>\n\n<\/div>\n\n\n<!-- STEPS 6\u201314 \u2014 Dynamic questions 11\u201319 -->\n<div class=\"glp-step\" data-step=\"6\">\n\n    \n    <div class=\"glp-question-block  wrap_question_11\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Are you currently taking any GLP-1 medications?            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_11\"\n                value=\"Yes\"\n                required            >\n                                    Yes        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_11\"\n                value=\"No\"\n                            >\n                                    No        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"next\">Continue<\/button>\n    <\/div>\n\n<\/div>\n<div class=\"glp-step\" data-step=\"7\">\n\n    \n    <div class=\"glp-question-block  wrap_question_12\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Are you currently pregnant, breastfeeding, or planning to become pregnant within the next 2 months?            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_12\"\n                value=\"Yes\"\n                required            >\n                                    Yes        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_12\"\n                value=\"No\"\n                            >\n                                    No        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"next\">Continue<\/button>\n    <\/div>\n\n<\/div>\n<div class=\"glp-step\" data-step=\"8\">\n\n    \n    <div class=\"glp-question-block  wrap_question_13\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Do you have any of the following conditions? Did you have any in the past? (Select any that apply.)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-options\">\n                \n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Gastroparesis\"\n                            required                        >\n                        Gastroparesis                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Pancreatic Cancer\"\n                            required                        >\n                        Pancreatic Cancer                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Pancreatitis\"\n                            required                        >\n                        Pancreatitis                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Type 1 diabetes or diabetes requiring insulin\"\n                            required                        >\n                        Type 1 diabetes or diabetes requiring insulin                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Hypoglycemia\"\n                            required                        >\n                        Hypoglycemia                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Medullary Thyroid Cancer (MTC) or family history of MTC\"\n                            required                        >\n                        Medullary Thyroid Cancer (MTC) or family history of MTC                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Bipolar Disorder\"\n                            required                        >\n                        Bipolar Disorder                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Schizophrenia\"\n                            required                        >\n                        Schizophrenia                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Family or personal history of Multiple Endocrine Neoplasia (MEN-2) syndrome\"\n                            required                        >\n                        Family or personal history of Multiple Endocrine Neoplasia (MEN-2) syndrome                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Anorexia or Bulimia\"\n                            required                        >\n                        Anorexia or Bulimia                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Current symptomatic gallstones or active gallbladder disease\"\n                            required                        >\n                        Current symptomatic gallstones or active gallbladder disease                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Active Substance Abuse Disorder\"\n                            required                        >\n                        Active Substance Abuse Disorder                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"None of the above\"\n                            required                        >\n                        None of the above                    <\/label>\n                            <\/div>\n\n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"next\">Continue<\/button>\n    <\/div>\n\n<\/div>\n<div class=\"glp-step\" data-step=\"9\">\n\n    \n    <div class=\"glp-question-block  wrap_question_14\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Please check all current or past medical conditions. Select all that apply            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-options\">\n                \n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Hypertension (high blood pressure)\"\n                            required                        >\n                        Hypertension (high blood pressure)                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\" High cholesterol\"\n                            required                        >\n                         High cholesterol                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\" Type 2 diabetes\"\n                            required                        >\n                         Type 2 diabetes                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\" Obstructive sleep apnea\"\n                            required                        >\n                         Obstructive sleep apnea                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Gout\"\n                            required                        >\n                        Gout                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Metabolic syndrome\"\n                            required                        >\n                        Metabolic syndrome                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Heart disease, stroke, or peripheral vascular disease\"\n                            required                        >\n                        Heart disease, stroke, or peripheral vascular disease                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Heart Failure\"\n                            required                        >\n                        Heart Failure                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Atrial fibrillation or flutter\"\n                            required                        >\n                        Atrial fibrillation or flutter                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Tachycardia or fast heart rate\"\n                            required                        >\n                        Tachycardia or fast heart rate                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Any ECG abnormality or heart rhythm abnormality\"\n                            required                        >\n                        Any ECG abnormality or heart rhythm abnormality                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Gallbladder removed\"\n                            required                        >\n                        Gallbladder removed                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Fatty Liver (MASLD or MASH)\"\n                            required                        >\n                        Fatty Liver (MASLD or MASH)                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Cirrhosis or end-stage liver disease\"\n                            required                        >\n                        Cirrhosis or end-stage liver disease                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Chronic Kidney Disease Stage 3 or greater\"\n                            required                        >\n                        Chronic Kidney Disease Stage 3 or greater                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Hypothyroidism, Hyperthyroidism, or Thyroid Issues\"\n                            required                        >\n                        Hypothyroidism, Hyperthyroidism, or Thyroid Issues                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"None of the Above\"\n                            required                        >\n                        None of the Above                    <\/label>\n                            <\/div>\n\n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"next\">Continue<\/button>\n    <\/div>\n\n<\/div>\n<div class=\"glp-step\" data-step=\"10\">\n\n    \n    <div class=\"glp-question-block  wrap_question_15\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Are you currently taking any medications, including prescriptions, over-the-counter meds, or supplements? If yes, please list them here! (The more details, the better!)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-field\">\n                <input \n                    id =\"question_15\"\n                    type=\"text\"\n                    name=\"question_15\"\n                    class=\"glp-input\"\n                    required                >\n            <\/div>\n\n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"next\">Continue<\/button>\n    <\/div>\n\n<\/div>\n<div class=\"glp-step\" data-step=\"11\">\n\n    \n    <div class=\"glp-question-block  wrap_question_16\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Do you have any allergies? (If none, just type \u201cN\/A.\u201d)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-field\">\n                <input \n                    id =\"question_16\"\n                    type=\"text\"\n                    name=\"question_16\"\n                    class=\"glp-input\"\n                    required                >\n            <\/div>\n\n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"next\">Continue<\/button>\n    <\/div>\n\n<\/div>\n<div class=\"glp-step\" data-step=\"12\">\n\n    \n    <div class=\"glp-question-block  wrap_question_17\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        List any surgeries you have had in the past: If you haven&#039;t had any surgeries, type N\/A             <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-field\">\n                <input \n                    id =\"question_17\"\n                    type=\"text\"\n                    name=\"question_17\"\n                    class=\"glp-input\"\n                    required                >\n            <\/div>\n\n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"next\">Continue<\/button>\n    <\/div>\n\n<\/div>\n<div class=\"glp-step\" data-step=\"13\">\n\n    \n    <div class=\"glp-question-block  wrap_question_18\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Please upload a government-issued photo ID             <span class=\"required\">*<\/span>        <\/p>\n\n                    <div class=\"glp-text sub-heading\">\n                You may upload any government-issued photo ID, including a driver's \n                license, passport, state ID, or foreign government-issued ID, such as a Mexican ID.<\/div>\n            <div class=\"glp-field care-glp-upload-box\">\n\n    <label class=\"glp-upload-box\">\n\n        <input \n            type=\"file\"\n            name=\"question_18\"\n            accept=\"image\/*,.pdf\"\n            class=\"glp-input user_id_file\"\n            hidden\n            required        >\n\n        <div class=\"glp-upload-content\">\n            <p>Drag & drop your file here or click to upload<\/p>\n            <small>Accepted: JPG, PNG, PDF (Max 5MB)<\/small>\n        <\/div>\n\n    <\/label>\n\n    <div class=\"glp-file-preview\"><\/div>\n\n    <small class=\"glp-error-text\"><\/small>\n\n<\/div>\n\n\n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"next\">Continue<\/button>\n    <\/div>\n\n<\/div>\n<div class=\"glp-step\" data-step=\"14\">\n\n    \n    <div class=\"glp-question-block  wrap_question_19\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Which type of consultation do you prefer? (Let us know what works best for you!)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_19\"\n                value=\"Email and Text Message (Fastest Option)\"\n                required            >\n                                    Email and Text Message (Fastest Option)        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_19\"\n                value=\"Video\"\n                            >\n                                    Video        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_19\"\n                value=\"Phone Call\"\n                            >\n                                    Phone Call        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"next\">Continue<\/button>\n    <\/div>\n\n<\/div>\n\n\n<!-- STEP 15 \u2014 Consent & Attestation -->\n<div class=\"glp-step\" data-step=\"15\">\n\n  <h2>Consent & Attestation<\/h2>\n\n  <div class=\"glp-question-block consent-hide-q custom-input\">\n\n    <p class=\"glp-question mb-5\">\n      Please review and attest to the following before continuing.      <br>\n      <strong>Consent:<\/strong>\n      I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care.      <span class=\"required\">*<\/span>\n    <\/p>\n\n    \n    <div class=\"glp-question-block  wrap_question_20\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Final Step! \u2013 Please confirm that all the information you&#039;ve provided is true and complete.Consent: I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care.            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n    \n        <label class=\"glp-option single-option\">\n            <input \n                type=\"checkbox\"\n                name=\"question_20[]\"\n                value=\"I agree and consent\"\n                required            >\n                                    I agree and consent        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n    \n    <small class=\"glp-error-text\" data-error=\"consent\"><\/small>\n\n  <\/div>\n\n  <div class=\"glp-navigation\">\n    <button type=\"button\" class=\"prev\">Back<\/button>\n    <button type=\"button\" class=\"next\">Continue<\/button>\n  <\/div>\n\n<\/div>\n\n\n<!-- STEP 16 \u2014 Billing Information -->\n<div class=\"glp-step\" data-step=\"16\">\n\n  <h2 class=\"mb-5\">Billing Information<\/h2>\n\n  <div class=\"glp-row\">\n\n    <div class=\"glp-field mb-3\">\n      <label>Address <span class=\"required\">*<\/span><\/label>\n      <input type=\"text\" name=\"street\" id=\"street\"\n        placeholder=\"House No, Building\" required>\n      <small class=\"glp-error-text\" data-error=\"street\"><\/small>\n    <\/div>\n\n    <div class=\"glp-field mb-3\">\n      <label>Street Address<\/label>\n      <input type=\"text\" name=\"street2\" id=\"street2\"\n        placeholder=\"Street name\">\n    <\/div>\n\n  <\/div>\n\n  <div class=\"glp-row\">\n\n    <div class=\"glp-field mb-3\">\n      <label>City <span class=\"required\">*<\/span><\/label>\n      <input type=\"text\" name=\"city\" id=\"city\" required>\n      <small class=\"glp-error-text\" data-error=\"city\"><\/small>\n    <\/div>\n\n    <div class=\"glp-field mb-3\">\n      <label for=\"state\">State \/ Province <span class=\"required\">*<\/span><\/label>\n      <select name=\"state\" id=\"state\" required>\n        <option value=\"\">Select State<\/option>\n        <option value=\"AL\">Alabama<\/option><option value=\"AK\">Alaska<\/option>\n        <option value=\"AZ\">Arizona<\/option><option value=\"AR\">Arkansas<\/option>\n        <option value=\"CA\">California<\/option><option value=\"CO\">Colorado<\/option>\n        <option value=\"CT\">Connecticut<\/option><option value=\"DE\">Delaware<\/option>\n        <option value=\"FL\">Florida<\/option><option value=\"GA\">Georgia<\/option>\n        <option value=\"HI\">Hawaii<\/option><option value=\"ID\">Idaho<\/option>\n        <option value=\"IL\">Illinois<\/option><option value=\"IN\">Indiana<\/option>\n        <option value=\"IA\">Iowa<\/option><option value=\"KS\">Kansas<\/option>\n        <option value=\"KY\">Kentucky<\/option><option value=\"LA\">Louisiana<\/option>\n        <option value=\"ME\">Maine<\/option><option value=\"MD\">Maryland<\/option>\n        <option value=\"MA\">Massachusetts<\/option><option value=\"MI\">Michigan<\/option>\n        <option value=\"MN\">Minnesota<\/option><option value=\"MS\">Mississippi<\/option>\n        <option value=\"MO\">Missouri<\/option><option value=\"MT\">Montana<\/option>\n        <option value=\"NE\">Nebraska<\/option><option value=\"NV\">Nevada<\/option>\n        <option value=\"NH\">New Hampshire<\/option><option value=\"NJ\">New Jersey<\/option>\n        <option value=\"NM\">New Mexico<\/option><option value=\"NY\">New York<\/option>\n        <option value=\"NC\">North Carolina<\/option><option value=\"ND\">North Dakota<\/option>\n        <option value=\"OH\">Ohio<\/option><option value=\"OK\">Oklahoma<\/option>\n        <option value=\"OR\">Oregon<\/option><option value=\"PA\">Pennsylvania<\/option>\n        <option value=\"RI\">Rhode Island<\/option><option value=\"SC\">South Carolina<\/option>\n        <option value=\"SD\">South Dakota<\/option><option value=\"TN\">Tennessee<\/option>\n        <option value=\"TX\">Texas<\/option><option value=\"UT\">Utah<\/option>\n        <option value=\"VT\">Vermont<\/option><option value=\"VA\">Virginia<\/option>\n        <option value=\"WA\">Washington<\/option><option value=\"WV\">West Virginia<\/option>\n        <option value=\"WI\">Wisconsin<\/option><option value=\"WY\">Wyoming<\/option>\n      <\/select>\n      <small class=\"glp-error-text\" data-error=\"state\"><\/small>\n    <\/div>\n\n  <\/div>\n\n  <div class=\"glp-row\">\n\n    <div class=\"glp-field mb-3\">\n      <label>ZIP \/ Postal Code <span class=\"required\">*<\/span><\/label>\n      <input type=\"text\" name=\"zip\" id=\"zip\" required>\n      <small class=\"glp-error-text\" data-error=\"zip\"><\/small>\n    <\/div>\n\n    <div class=\"glp-field mb-3\">\n      <label>Country<\/label>\n      <select name=\"country\" id=\"country\">\n        <option value=\"US\">United States<\/option>\n      <\/select>\n    <\/div>\n\n  <\/div>\n\n  <div class=\"glp-navigation\">\n    <button type=\"button\" class=\"prev\">Back<\/button>\n    <button type=\"button\" class=\"next\">Continue<\/button>\n  <\/div>\n\n<\/div>\n\n\n<!-- STEP 17 \u2014 Payment (Stripe) -->\n<div class=\"glp-step stripe-page step-end\" data-step=\"17\">\n\n  <div class=\"glp-question-block\">\n\n    <div class=\"glp-field mb-3\">\n      <label for=\"promo_code\">Promo Code<\/label>\n      <input type=\"text\" name=\"promo_code\" id=\"promo_code\"\n        placeholder=\"Enter promo code\">\n    <\/div>\n\n    <div class=\"glp-field mb-3\">\n      <label>Payment <span class=\"required\">*<\/span><\/label>\n      <div id=\"card-element\" class=\"glp-stripe-card\"><\/div>\n      <div id=\"card-errors\" class=\"glp-error-text\"><\/div>\n      <div id=\"stripeFields\"><\/div>\n      <div id=\"stripeErrors\"><\/div>\n      <div 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