{"id":599,"date":"2026-02-11T06:16:07","date_gmt":"2026-02-11T06:16:07","guid":{"rendered":"http:\/\/www.avonleaclinic.com.au\/upgrade\/?page_id=599"},"modified":"2026-02-11T06:43:16","modified_gmt":"2026-02-11T06:43:16","slug":"pain-questionnaire","status":"publish","type":"page","link":"http:\/\/www.avonleaclinic.com.au\/upgrade\/pain-questionnaire\/","title":{"rendered":"Pain Questionnaire"},"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;331&#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;125697&#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;373794&#8243; heading_custom_size=&#8221;100&#8243;]Pain questionnaire[\/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;775871&#8243;]Please complete this form before your appointment to help us better understand your symptoms and tailor your care.[\/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;199912&#8243; text_color_type=&#8221;uncode-palette&#8221;]Pain questionnaire[\/vc_custom_heading][vc_custom_heading text_size=&#8221;h1&#8243; uncode_shortcode_id=&#8221;130394&#8243;]To help us understand your symptoms and tailor your care, please complete the pelvic pain questionnaire before your first appointment.[\/vc_custom_heading][vc_column_text text_lead=&#8221;yes&#8221; uncode_shortcode_id=&#8221;142946&#8243;]Your responses give our team valuable insight and help us focus your consultation on what matters most to you.<\/p>\n<p>Firstly, please download, fill and upload the completed Pelvic Pain Questionnaire form.[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column width=&#8221;1\/1&#8243;][vc_button button_color=&#8221;accent&#8221; size=&#8221;btn-lg&#8221; border_width=&#8221;0&#8243; link=&#8221;url:http%3A%2F%2Fwww.avonleaclinic.com.au%2Fupgrade%2Fwp-content%2Fuploads%2F2026%2F02%2FPain-Patient-Questionnaire-Form-2.pdf|target:_blank&#8221; uncode_shortcode_id=&#8221;167963&#8243; button_color_type=&#8221;uncode-palette&#8221;]Download Pelvic Pain Questionnaire Form[\/vc_button][\/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; uncode_shortcode_id=&#8221;295240&#8243; back_size=&#8221;contain&#8221;][vc_column width=&#8221;1\/1&#8243;]<script 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data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_page_5_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_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_54\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload 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_5_54'>Upload your completed Pelvic Pain Questionnaire<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='2097152' \/><input name='input_54' id='input_5_54' type='file' class='medium' aria-describedby=\"gfield_upload_rules_5_54\" onchange='javascript:gformValidateFileSize( this, 2097152 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_54'>Max. file size: 2 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_5_54'><\/div> <\/div><\/div><div id=\"field_5_55\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_5_52\" class=\"gfield gfield--type-select gfield--input-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_5_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_5_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 Adlina Hanafiah' >Dr Adlina Hanafiah<\/option><\/select><\/div><\/div><div id=\"field_5_60\" class=\"gfield gfield--type-text gfield--input-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_5_60'>Title<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_5_60' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_1\" class=\"gfield gfield--type-name gfield--input-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_5_1'>\n                            \n                            <span id='input_5_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_5_1_3' value=''   aria-required='true'   placeholder='First name'  \/>\n                                                    <label for='input_5_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_5_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_5_1_6' value=''   aria-required='true'   placeholder='Surname'  \/>\n                                                    <label for='input_5_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_5_61\" class=\"gfield gfield--type-text gfield--input-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_5_61'>Gender<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_5_61' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_62\" class=\"gfield gfield--type-text gfield--input-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_5_62'>Preferred Pronouns<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_5_62' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_2\" class=\"gfield gfield--type-address gfield--input-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_5_2' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_2_1_container' >\n                                        <input type='text' name='input_2.1' id='input_5_2_1' value=''   placeholder='Street Address' aria-required='true'    \/>\n                                        <label for='input_5_2_1' id='input_5_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_5_2_2_container' >\n                                        <input type='text' name='input_2.2' id='input_5_2_2' value=''   placeholder='Address Line 2'  aria-required='false'   \/>\n                                        <label for='input_5_2_2' id='input_5_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_5_2_3_container' >\n                                    <input type='text' name='input_2.3' id='input_5_2_3' value=''   placeholder='City' aria-required='true'    \/>\n                                    <label for='input_5_2_3' id='input_5_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_5_2_4_container' >\n                                        <input type='text' name='input_2.4' id='input_5_2_4' value=''     placeholder='State' aria-required='true'    \/>\n                                        <label for='input_5_2_4' id='input_5_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_5_2_5_container' >\n                                    <input type='text' name='input_2.5' id='input_5_2_5' value=''   placeholder='Postal Code' aria-required='true'    \/>\n                                    <label for='input_5_2_5' id='input_5_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_5_2_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_4\" class=\"gfield gfield--type-text gfield--input-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_5_4'>Home phone<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_5_4' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_5\" class=\"gfield gfield--type-text gfield--input-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_5_5'>Work phone<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_5_5' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_6\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_6' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_26\" class=\"gfield gfield--type-select gfield--input-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_5_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_5_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_5_8\" class=\"gfield gfield--type-email gfield--input-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_5_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_5_8' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_25\" class=\"gfield gfield--type-select gfield--input-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_5_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_5_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_5_59\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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_5_59'>\n\t\t\t<div class='gchoice gchoice_5_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Yes'  id='choice_5_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_59_0' id='label_5_59_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_5_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='No'  id='choice_5_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_59_1' id='label_5_59_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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_5_63'>\n\t\t\t<div class='gchoice gchoice_5_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Yes'  id='choice_5_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_63_0' id='label_5_63_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_5_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='No'  id='choice_5_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_63_1' id='label_5_63_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_64\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below 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_5_64'><div class='gchoice gchoice_5_64_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.1' type='checkbox'  value='I agree'  id='choice_5_64_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_64_1' id='label_5_64_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><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_5_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_5_2' class='gform_page' data-js='page-field-id-34' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_10\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_10' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_11\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_12\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_12' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_28\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_5_58\" class=\"gfield gfield--type-html gfield--input-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_5_13\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_13' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_14\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_14' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_15\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_15' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_16\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_16' type='text' value='' class='medium'    placeholder='Number left of your name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_36\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_36' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_17\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_17' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_18\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_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_5_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_5_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_5_3' class='gform_page' data-js='page-field-id-35' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_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_5_19' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_32\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_5_20\" class=\"gfield gfield--type-text gfield--input-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_5_20'>Refering 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_5_20' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_21\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_21' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_22\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_22' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_29\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_5_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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_5_23'>\n\t\t\t<div class='gchoice gchoice_5_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_5_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_23_0' id='label_5_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_5_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_5_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_23_1' id='label_5_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_5_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_5_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_5_4' class='gform_page' data-js='page-field-id-49' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_57\" class=\"gfield gfield--type-html gfield--input-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_5_37\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_37' type='text' value='' class='medium'    placeholder='E.g. Tonsils, Appendix, Teeth' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_38\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_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_5_39\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_39' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_40\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_40' type='text' value='' class='medium'    placeholder='Regular? Heavy? Painful?' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_41\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_41' type='text' value='' class='medium'    placeholder='Slow emptying, urgency, leaking' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_42\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_42' type='text' value='' class='medium'    placeholder='E.g. Slow, pain, bleeding' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_43\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_43' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_44\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_44' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_45\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_45' type='text' value='' class='medium'    placeholder='E.g. Bleeding, cancers, diabetes' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_46\" class=\"gfield gfield--type-text gfield--input-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_5_46'>Medications<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_5_46' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_47\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_47' type='text' value='' class='medium'    placeholder='E.g. Medicines, latex' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_48\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_48' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_50\" class=\"gfield gfield--type-text gfield--input-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_5_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_5_50' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_33\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_5_56\" class=\"gfield gfield--type-name gfield--input-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 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_5_56'>\n                            \n                            <span id='input_5_56_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_56.3' id='input_5_56_3' value=''   aria-required='true'   placeholder='First name'  \/>\n                                                    <label for='input_5_56_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_5_56_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_56.6' id='input_5_56_6' value=''   aria-required='true'   placeholder='Last name'  \/>\n                                                    <label for='input_5_56_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_5_24\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><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_5_24_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_5_24\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_24_1' >I agree<span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/label><input type='hidden' name='input_24.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_24.3' value='2' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_5_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_5' 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_5' 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_5' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_5' id='gform_theme_5' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_5' id='gform_style_settings_5' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='5' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='AUD' value='W0\/+UyK74Btv4RfMULGyfBJSiwNiLBnviRF2iuYPNhl7z0irg8R84SYF1H1bUQvin4lIppbTSwvvsdaKWB9y56QIgOmk4\/vW2HdMy+HycbAKCIs=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_5' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_5' id='gform_target_page_number_5' value='2' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_5' id='gform_source_page_number_5' 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( 5, 'http:\/\/www.avonleaclinic.com.au\/upgrade\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', false );jQuery('#gform_ajax_frame_5').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_5');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_5').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_5').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_5').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_5').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_5').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_5').val();gformInitSpinner( 5, 'http:\/\/www.avonleaclinic.com.au\/upgrade\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', false );jQuery(document).trigger('gform_page_loaded', [5, current_page]);window['gf_submitting_5'] = 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_5').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_5').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [5]);window['gf_submitting_5'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_5').text());}else{jQuery('#gform_5').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"5\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_5\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_5\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_5\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 5, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments; 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