{"id":585,"date":"2026-02-11T05:48:28","date_gmt":"2026-02-11T05:48:28","guid":{"rendered":"http:\/\/www.avonleaclinic.com.au\/upgrade\/?page_id=585"},"modified":"2026-02-11T06:02:24","modified_gmt":"2026-02-11T06:02:24","slug":"patient-registration","status":"publish","type":"page","link":"http:\/\/www.avonleaclinic.com.au\/upgrade\/patient-registration\/","title":{"rendered":"Patient Registration"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row row_height_percent=&#8221;80&#8243; back_color=&#8221;color-wayh&#8221; overlay_alpha=&#8221;50&#8243; gutter_size=&#8221;3&#8243; column_width_percent=&#8221;100&#8243; shift_y=&#8221;0&#8243; z_index=&#8221;0&#8243; content_parallax=&#8221;0&#8243; uncode_shortcode_id=&#8221;191419&#8243; back_color_type=&#8221;uncode-palette&#8221;][vc_column width=&#8221;1\/1&#8243;][uncode_slider slider_type=&#8221;fade&#8221; slider_interval=&#8221;5000&#8243; slider_navspeed=&#8221;400&#8243; slider_loop=&#8221;yes&#8221;][vc_row_inner row_inner_height_percent=&#8221;0&#8243; back_color=&#8221;color-wayh&#8221; back_image=&#8221;348&#8243; parallax=&#8221;yes&#8221; overlay_color=&#8221;color-wayh&#8221; overlay_alpha=&#8221;50&#8243; gutter_size=&#8221;3&#8243; shift_y=&#8221;0&#8243; z_index=&#8221;0&#8243; uncode_shortcode_id=&#8221;268024&#8243; back_color_type=&#8221;uncode-palette&#8221; overlay_color_type=&#8221;uncode-palette&#8221;][vc_column_inner column_width_percent=&#8221;100&#8243; position_vertical=&#8221;middle&#8221; align_horizontal=&#8221;align_center&#8221; gutter_size=&#8221;3&#8243; style=&#8221;dark&#8221; overlay_alpha=&#8221;50&#8243; shift_x=&#8221;0&#8243; shift_y=&#8221;0&#8243; shift_y_down=&#8221;0&#8243; z_index=&#8221;0&#8243; medium_width=&#8221;0&#8243; mobile_width=&#8221;0&#8243; zoom_width=&#8221;0&#8243; zoom_height=&#8221;0&#8243; width=&#8221;1\/1&#8243;][vc_custom_heading heading_semantic=&#8221;h1&#8243; text_size=&#8221;custom&#8221; css_animation=&#8221;bottom-t-top&#8221; animation_delay=&#8221;400&#8243; uncode_shortcode_id=&#8221;627195&#8243; heading_custom_size=&#8221;100&#8243;]Patient registration[\/vc_custom_heading][vc_column_text text_lead=&#8221;yes&#8221; css_animation=&#8221;bottom-t-top&#8221; animation_delay=&#8221;600&#8243; uncode_shortcode_id=&#8221;209568&#8243;]New to Avonlea Clinic? Please complete the registration form before your first appointment so we can prepare for your visit and provide the best care possible.[\/vc_column_text][\/vc_column_inner][\/vc_row_inner][\/uncode_slider][\/vc_column][\/vc_row][vc_row row_height_percent=&#8221;0&#8243; override_padding=&#8221;yes&#8221; h_padding=&#8221;2&#8243; top_padding=&#8221;5&#8243; bottom_padding=&#8221;2&#8243; overlay_alpha=&#8221;50&#8243; gutter_size=&#8221;3&#8243; column_width_percent=&#8221;100&#8243; shift_y=&#8221;0&#8243; z_index=&#8221;0&#8243; content_parallax=&#8221;0&#8243; uncode_shortcode_id=&#8221;188425&#8243;][vc_column width=&#8221;1\/1&#8243;][vc_custom_heading text_color=&#8221;accent&#8221; heading_semantic=&#8221;h6&#8243; text_size=&#8221;h6&#8243; text_transform=&#8221;uppercase&#8221; text_space=&#8221;fontspace-184360&#8243; uncode_shortcode_id=&#8221;397379&#8243; text_color_type=&#8221;uncode-palette&#8221;]Patient registration[\/vc_custom_heading][vc_custom_heading text_size=&#8221;h1&#8243; uncode_shortcode_id=&#8221;530125&#8243;]We kindly require a referral from your GP, along with any relevant test results, before we can schedule your appointment.[\/vc_custom_heading][vc_column_text text_lead=&#8221;yes&#8221; uncode_shortcode_id=&#8221;472855&#8243;]Once this information has been received, our reception team will be in touch to arrange a suitable time for your visit.[\/vc_column_text][\/vc_column][\/vc_row][vc_row row_height_percent=&#8221;0&#8243; override_padding=&#8221;yes&#8221; h_padding=&#8221;2&#8243; top_padding=&#8221;2&#8243; bottom_padding=&#8221;4&#8243; back_image=&#8221;575&#8243; back_repeat=&#8221;no-repeat&#8221; back_attachment=&#8221;scroll&#8221; back_position=&#8221;left bottom&#8221; parallax=&#8221;yes&#8221; kburns=&#8221;yes&#8221; overlay_alpha=&#8221;50&#8243; gutter_size=&#8221;3&#8243; column_width_percent=&#8221;100&#8243; shift_y=&#8221;0&#8243; z_index=&#8221;0&#8243; content_parallax=&#8221;0&#8243; 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data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_page_2_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_52\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_52'>Doctor to consult with<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_52' id='input_2_52' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='Dr Marilla Druitt' >Dr Marilla Druitt<\/option><option value='Dr Anne Hotchin' >Dr Anne Hotchin<\/option><option value='Dr Vidhu Krishnan' >Dr Vidhu Krishnan<\/option><option value='Dr Adlina Hanafiah' >Dr Adlina Hanafiah<\/option><\/select><\/div><\/div><div id=\"field_2_57\" class=\"gfield gfield--type-text gfield--width-full gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_57'>Title<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_2_57' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_1\" class=\"gfield gfield--type-name gf_right_half gfield--width-half gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_1'>\n                            \n                            <span id='input_2_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_2_1_3' value=''   aria-required='true'   placeholder='First name'  \/>\n                                                    <label for='input_2_1_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_2_1_6' value=''   aria-required='true'   placeholder='Surname'  \/>\n                                                    <label for='input_2_1_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Surname<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_58\" class=\"gfield gfield--type-text gfield--width-full gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_58'>Gender<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_2_58' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_59\" class=\"gfield gfield--type-text gfield--width-full gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_59'>Preferred Pronouns<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_2_59' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_2\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_2_2' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_2_1_container' >\n                                        <input type='text' name='input_2.1' id='input_2_2_1' value=''   placeholder='Street Address' aria-required='true'    \/>\n                                        <label for='input_2_2_1' id='input_2_2_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_2_2_2_container' >\n                                        <input type='text' name='input_2.2' id='input_2_2_2' value=''   placeholder='Address Line 2'  aria-required='false'   \/>\n                                        <label for='input_2_2_2' id='input_2_2_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_2_3_container' >\n                                    <input type='text' name='input_2.3' id='input_2_2_3' value=''   placeholder='City' aria-required='true'    \/>\n                                    <label for='input_2_2_3' id='input_2_2_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_2_4_container' >\n                                        <input type='text' name='input_2.4' id='input_2_2_4' value=''     placeholder='State' aria-required='true'    \/>\n                                        <label for='input_2_2_4' id='input_2_2_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_2_5_container' >\n                                    <input type='text' name='input_2.5' id='input_2_2_5' value=''   placeholder='Postal Code' aria-required='true'    \/>\n                                    <label for='input_2_2_5' id='input_2_2_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_2.6' id='input_2_2_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_2_4\" class=\"gfield gfield--type-text gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_4'>Home phone<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_2_4' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_5\" class=\"gfield gfield--type-text gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_5'>Work phone<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_2_5' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_6\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_6'>Mobile phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_2_6' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_26\" class=\"gfield gfield--type-select gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_26'>Consent to be contacted via SMS<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_2_26' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_2_8\" class=\"gfield gfield--type-email gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_8'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_8' id='input_2_8' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_25\" class=\"gfield gfield--type-select gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_25'>Consent to be contacted via email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_2_25' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><fieldset id=\"field_2_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you been fully vaccinated against COVID-19?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_60'>\n\t\t\t<div class='gchoice gchoice_2_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Yes'  id='choice_2_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_60_0' id='label_2_60_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='No'  id='choice_2_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_60_1' id='label_2_60_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you agree to have a medical student sit in on your consultation?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_56'>\n\t\t\t<div class='gchoice gchoice_2_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Yes'  id='choice_2_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_56_0' id='label_2_56_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='No'  id='choice_2_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_56_1' id='label_2_56_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_2_34' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_2' class='gform_page' data-js='page-field-id-34' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_10\" class=\"gfield gfield--type-text gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_10'>Next of kin<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_2_10' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_11\" class=\"gfield gfield--type-text gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_11'>Relationship<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_2_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_12\" class=\"gfield gfield--type-text gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_12'>Next of kin phone number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_2_12' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_28\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_2_55\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><i>Note: Please enter 'Nil' if question doesn't apply.<\/i><\/div><div id=\"field_2_13\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_13'>Hospital health cover<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_2_13' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_14\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_14'>Membership number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_2_14' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_15\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_15'>Medicare number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_2_15' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_16\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_16'>Card reference number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_2_16' type='text' value='' class='medium'    placeholder='Number left of your name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_36\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_36'>Health care card<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_2_36' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_17\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_17'>Aged pension number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_2_17' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_18\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_18'>Veterans affairs # VX<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_2_18' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_35' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_2_35' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_3' class='gform_page' data-js='page-field-id-35' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_19\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_19'>Person responsible for the account<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_2_19' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_32\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_2_20\" class=\"gfield gfield--type-text gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_20'>Referring doctor<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_2_20' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_21\" class=\"gfield gfield--type-text gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_21'>Usual doctor<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_2_21' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_22\" class=\"gfield gfield--type-text gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_22'>Other doctors treating you<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_2_22' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_29\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_2_23\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you Aboriginal and \/ or Torres Straight Islander<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_23'>\n\t\t\t<div class='gchoice gchoice_2_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_2_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_23_0' id='label_2_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_2_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_23_1' id='label_2_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_49' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_2_49' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_4' class='gform_page' data-js='page-field-id-49' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_54\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><i>Note: Please enter 'Nil' if question doesn't apply.<\/i><\/div><div id=\"field_2_37\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_37'>Past surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_2_37' type='text' value='' class='medium'    placeholder='E.g. Tonsils, Appendix, Teeth' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_38\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_38'>Medical problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_2_38' type='text' value='' class='medium'    placeholder='E.g. High BP, Migraine, DVT, Genital Herpes' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_39\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_39'>Mental health problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_2_39' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_62\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have any neurodevelopmental or neurodivergent conditions?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_62'>\n\t\t\t<div class='gchoice gchoice_2_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Yes'  id='choice_2_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_62_0' id='label_2_62_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='No'  id='choice_2_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_62_1' id='label_2_62_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_40\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_40'>Periods<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_2_40' type='text' value='' class='medium'    placeholder='Regular? Heavy? Painful?' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_41\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_41'>Bladder problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_2_41' type='text' value='' class='medium'    placeholder='Slow emptying, urgency, leaking' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_42\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_42'>Bowel problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_2_42' type='text' value='' class='medium'    placeholder='E.g. Slow, pain, bleeding' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_43\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_43'>Pregnancies, Births<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_2_43' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_44\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_44'>Last Cervical Screening test (PAP)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_2_44' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_45\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_45'>Family history<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_2_45' type='text' value='' class='medium'    placeholder='E.g. Bleeding, cancers, diabetes' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_46\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_46'>Medications and Supplements<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_2_46' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_47\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_47'>Allergies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_2_47' type='text' value='' class='medium'    placeholder='E.g. Medicines, latex' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_48\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_48'>Smoke? Drink alcohol? Any others?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_2_48' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_50\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_50'>Contraception?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_2_50' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_33\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_2_53\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_53'>\n                            \n                            <span id='input_2_53_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_53.3' id='input_2_53_3' value=''   aria-required='true'   placeholder='First name'  \/>\n                                                    <label for='input_2_53_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_53_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_53.6' id='input_2_53_6' value=''   aria-required='true'   placeholder='Last name'  \/>\n                                                    <label for='input_2_53_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_2_65\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I give my permission for my medical records to be obtained from or sent to any specified doctor and or medical institute. I give consent for my doctor to submit their account for my surgical procedure to my health fund on my behalf. I hereby agree to pay all costs incurred for my care and treatment by my doctor.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_65'><div class='gchoice gchoice_2_65_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.1' type='checkbox'  value='I agree'  id='choice_2_65_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_65_1' id='label_2_65_1' class='gform-field-label gform-field-label--type-inline'>I agree<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_24\" class=\"gfield gfield--type-consent gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_24.1' id='input_2_24_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_2_24\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_24_1' >I agree<\/label><input type='hidden' name='input_24.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_24.3' value='1' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_2_24' tabindex='0'>I give my permission for my medical records to be obtained from or sent to any specified doctor and or medical institute. I give consent for my doctor to submit their account for my surgical procedure to my health fund on my behalf. I hereby agree to pay all costs incurred for my care and treatment by my doctor.<\/div><\/fieldset><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_2' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_2' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_2' id='gform_theme_2' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_2' id='gform_style_settings_2' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='AUD' value='EAH3uztYrx+6aQRk0GhvBoXLGql6kATvTOc+79qnXHa7TvmOmcqivMtixUXR8R3EMSXLQ+D2o7iSGzVwv+YiTIeID3DepFBTweITzs29YMp2Y6I=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_2' id='gform_target_page_number_2' value='2' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_2' id='gform_source_page_number_2' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n             <\/div><\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 2, 'http:\/\/www.avonleaclinic.com.au\/upgrade\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', false );jQuery('#gform_ajax_frame_2').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_2');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_2').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_2').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_2').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_2').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_2').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_2').val();gformInitSpinner( 2, 'http:\/\/www.avonleaclinic.com.au\/upgrade\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', false );jQuery(document).trigger('gform_page_loaded', [2, current_page]);window['gf_submitting_2'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_2').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_2').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [2]);window['gf_submitting_2'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_2').text());}else{jQuery('#gform_2').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"2\", currentPage: \"current_page\", abort: function() { this.preventDefault(); 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