marcharriganmd.com
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Submitted URL: https://harriganenroll.com/
Effective URL: https://marcharriganmd.com/online-enrollment/
Submission: On October 28 via api from US — Scanned from DE
Effective URL: https://marcharriganmd.com/online-enrollment/
Submission: On October 28 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST /online-enrollment/#gf_7
<form method="post" enctype="multipart/form-data" id="gform_7" action="/online-enrollment/#gf_7" data-formid="7" novalidate="">
<div id="gf_progressbar_wrapper_7" class="gf_progressbar_wrapper" data-start-at-zero="">
<p class="gf_progressbar_title">Step <span class="gf_step_current_page">1</span> of <span class="gf_step_page_count">3</span> - Agreement </p>
<div class="gf_progressbar gf_progressbar_blue" aria-hidden="true">
<div class="gf_progressbar_percentage percentbar_blue percentbar_33" style="width: 33%;"><span>33%</span></div>
</div>
</div>
<div class="gform-body gform_body">
<div id="gform_page_7_1" class="gform_page " data-js="page-field-id-1">
<div class="gform_page_fields">
<div id="gform_fields_7" class="gform_fields top_label form_sublabel_above description_above validation_below">
<div id="field_7_15"
class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_15">
<p>I have engaged Harrigan Medical Consulting Services, Inc. (HMCS), dba Concierge Medicine of Buckhead, to provide non-covered, non-clinical amenities and benefits to me for an initial period of one year beginning October 28, 2024. I
understand that this Agreement will renew automatically following the end of each one-year period unless I provide the Company with a written notice of non- renewal at least 30 days before the end of a Service Year. I further understand
that I will be required to pay a yearly membership fee at the start of each renewal term for these non-covered services, amenities, and benefits. As used in this Agreement, the term “Service Year” refers to the one-year period beginning
on October 28, 2024, as well as every one-year renewal period thereafter.</p>
</div>
<div id="field_7_135"
class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_135">
<style>
#pricing-explained {
display: flex;
flex-wrap: wrap;
}
#pricing-explained>ul {
list-style: none;
flex-basis: 300px;
flex-grow: 1;
margin-left: 0 !important;
}
#pricing-explained>ul>li {
list-style: none !important;
}
#pricing-explained>p {
margin-bottom: 0 !important;
font-weight: bold;
flex-basis: 100%;
}
#pricing-explained span {}
</style>
<br>
<div id="pricing-explained">
<ul style="margin: 0; padding: 0;">
<li>
<span>$2,500/year = Individual </span>
</li>
<li>
<span>$4,500/year = Couple</span>
</li>
<li>
<span>No charge for children of member (ages 12 up to 26 as of date of enrollment) </span>
</li>
</ul>
</div>
</div>
<div id="field_7_140" class="gfield gfield--type-select gfield--input-type-select field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_140"><label
class="gfield_label gform-field-label" for="input_7_140">Individuals (27 and over)</label>
<div class="ginput_container ginput_container_select"><select name="input_140" id="input_7_140" class="medium gfield_select" tabindex="1" aria-invalid="false">
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
</select></div>
</div>
<div id="field_7_142" class="gfield gfield--type-select gfield--input-type-select field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_142"
data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_142">Individuals (between the ages of 12 and 26)</label>
<div class="ginput_container ginput_container_select"><select name="input_142" id="input_7_142" class="medium gfield_select" aria-invalid="false" disabled="disabled">
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
</select></div>
</div>
<div id="field_7_153" class="gfield gfield--type-number gfield--input-type-number gfield_calculation field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_hidden"
data-js-reload="field_7_153">
<div class="admin-hidden-markup"><i class="gform-icon gform-icon--hidden"></i><span>Hidden</span></div><label class="gfield_label gform-field-label" for="input_7_153">Total members</label>
<div class="gfield_description" id="gfield_description_7_153">(will be hidden, for logic only)</div>
<div class="ginput_container ginput_container_number"><input name="input_153" id="input_7_153" type="text" step="any" value="" class="medium" tabindex="3" readonly="readonly" aria-invalid="false"
aria-describedby="gfield_description_7_153"></div>
</div>
<div id="field_7_301"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_7_301 gfield_product_7_301 gfield_calculation field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_301" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_7_301_1">Individuals (27 and over)</label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_301.1" value="Individuals (27 and over)" class="gform_hidden" disabled="disabled">
<div id="ginput_product_price_7_301" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_7_301">$0.00</span>
</div>
<input type="hidden" name="input_301.2" id="ginput_base_price_7_301" class="gform_hidden" value="$0.00" disabled="disabled">
<input type="hidden" name="input_301.3" value="1" class="ginput_quantity_7_301 gform_hidden" disabled="disabled">
</div>
</div>
<div id="field_7_303"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_7_303 gfield_product_7_303 gfield_calculation field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_303" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_7_303_1">Couples Discount</label>
<div class="gfield_description" id="gfield_description_7_303">Applied for the first additional adult over the age of 27.</div>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_303.1" value="Couples Discount" class="gform_hidden" disabled="disabled">
<div id="ginput_product_price_7_303" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_7_303">-$500.00</span>
</div>
<input type="hidden" name="input_303.2" id="ginput_base_price_7_303" class="gform_hidden" value="-$500.00" disabled="disabled">
<input type="hidden" name="input_303.3" value="1" class="ginput_quantity_7_303 gform_hidden" disabled="disabled">
</div>
</div>
<div id="field_7_327"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_7_327 gfield_product_7_327 gfield_calculation field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_327"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_7_327_1">Dependents</label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_327.1" value="Dependents" class="gform_hidden">
<div id="ginput_product_price_7_327" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_7_327">$0.00</span>
</div>
<input type="hidden" name="input_327.2" id="ginput_base_price_7_327" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_327.3" value="1" class="ginput_quantity_7_327 gform_hidden">
</div>
</div>
<div id="field_7_304"
class="gfield gfield--type-total gfield--input-type-total gfield--width-full gfield_price gfield_price_7_ gfield_total gfield_total_7_ field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
aria-atomic="true" aria-live="polite" data-js-reload="field_7_304"><label class="gfield_label gform-field-label" for="input_7_304">Total</label>
<div class="ginput_container ginput_container_total">
<input type="text" readonly="" name="input_304" id="input_7_304" value="$0.00" class="gform-text-input-reset ginput_total ginput_total_7">
</div>
</div>
<div id="field_7_17"
class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_17"><strong>This Agreement is for non-covered primary care services and other amenities and benefits as described in the Highlights & Details document.</strong> I have read and understand this Agreement as well
as the <a href="https://marcharriganmd.com/wp-content/uploads/2023/02/HarriganMD_HDs.pdf" target="_blank">Highlights & Details (H&Ds)</a> and
<a href="https://marcharriganmd.com/wp-content/uploads/2023/02/HarriganMD_FAQs.pdf" target="_blank">Frequently Asked Questions (FAQs)</a> materials provided to me by HMCS. I understand that this Agreement can be terminated upon 30 days
written notice. If the agreement is terminated, I may receive a refund of the pro-rated portion of the paid annual fee, based on the number of days that have elapsed in the Service Year, to be determined by HMCS, on a case-by-case basis.
Such refund will be paid to me within 30 days after termination. This Agreement will automatically renew for subsequent Service Years under the same payment terms unless I notify HMCS otherwise (or HMCS notifies me) within 30 days of the
next payment due date.</div>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_next_button_7_163" class="gform_next_button gform-theme-button button" value="Next" tabindex="4"
onclick="jQuery("#gform_target_page_number_7").val("2"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("2"); jQuery("#gform_7").trigger("submit",[true]); } " disabled="disabled" data-conditional-logic="hidden"
style="display: none;">
</div>
</div>
<div id="gform_page_7_2" class="gform_page" data-js="page-field-id-163" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_7_2" class="gform_fields top_label form_sublabel_above description_above validation_below">
<div id="field_7_19" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_19"
data-conditional-logic="hidden" style="display: none;">
<h3 class="gsection_title">1st Individual (27 and over)</h3>
</div>
<fieldset id="field_7_20" class="gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_20" data-conditional-logic="hidden" style="display: none;">
<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_7_20">
<span id="input_7_20_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<label for="input_7_20_3" class="gform-field-label gform-field-label--type-sub ">First</label>
<input type="text" name="input_20.3" id="input_7_20_3" value="" tabindex="6" aria-required="true" disabled="disabled">
</span>
<span id="input_7_20_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<label for="input_7_20_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
<input type="text" name="input_20.6" id="input_7_20_6" value="" tabindex="8" aria-required="true" disabled="disabled">
</span>
</div>
</fieldset>
<div id="field_7_21"
class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_21" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_21">Date of Birth<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_21" id="input_7_21" type="text" value="" class="datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" tabindex="10" placeholder="mm/dd/yyyy"
aria-describedby="input_7_21_date_format" aria-invalid="false" aria-required="true" disabled="disabled"><img class="ui-datepicker-trigger"
src="https://marcharriganmd.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_7_21_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_7_21" class="gform_hidden" value="https://marcharriganmd.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" disabled="disabled">
</div>
<div id="field_7_22" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_22" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_22">Gender<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_22" id="input_7_22" class="medium gfield_select" aria-required="true" aria-invalid="false" disabled="disabled">
<option value="Male">Male</option>
<option value="Female">Female</option>
<option value="Prefer Not to Answer">Prefer Not to Answer</option>
</select></div>
</div>
<div id="field_7_98" class="gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_98" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_98">Daytime Phone Number<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_98" id="input_7_98" type="tel" value="" class="medium" tabindex="12" aria-required="true" aria-invalid="false" disabled="disabled"></div>
</div>
<fieldset id="field_7_120"
class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_120" data-conditional-logic="hidden" style="display: none;">
<legend class="gfield_label gform-field-label">Is this a cell number?<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_7_120">
<div class="gchoice gchoice_7_120_0">
<input class="gfield-choice-input" name="input_120" type="radio" value="Yes" id="choice_7_120_0" onchange="gformToggleRadioOther( this )" tabindex="13" disabled="disabled">
<label for="choice_7_120_0" id="label_7_120_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_7_120_1">
<input class="gfield-choice-input" name="input_120" type="radio" value="No" id="choice_7_120_1" onchange="gformToggleRadioOther( this )" tabindex="14" disabled="disabled">
<label for="choice_7_120_1" id="label_7_120_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_7_310"
class="gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_310" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_310">Cell Phone Number<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_310" id="input_7_310" type="tel" value="" class="medium" tabindex="15" aria-required="true" aria-invalid="false" disabled="disabled"></div>
</div>
<div id="field_7_23" class="gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_23" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_23">Email<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_23" id="input_7_23" type="email" value="" class="medium" tabindex="16" aria-required="true" aria-invalid="false" disabled="disabled">
</div>
</div>
<div id="field_7_29" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_29"
data-conditional-logic="hidden" style="display: none;">
<h3 class="gsection_title">2nd Individual (27 and over)</h3>
</div>
<fieldset id="field_7_30" class="gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_30" data-conditional-logic="hidden" style="display: none;">
<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_7_30">
<span id="input_7_30_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<label for="input_7_30_3" class="gform-field-label gform-field-label--type-sub ">First</label>
<input type="text" name="input_30.3" id="input_7_30_3" value="" tabindex="18" aria-required="true" disabled="disabled">
</span>
<span id="input_7_30_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<label for="input_7_30_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
<input type="text" name="input_30.6" id="input_7_30_6" value="" tabindex="20" aria-required="true" disabled="disabled">
</span>
</div>
</fieldset>
<div id="field_7_31"
class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_31" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_31">Date of Birth<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_31" id="input_7_31" type="text" value="" class="datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" tabindex="22" placeholder="mm/dd/yyyy"
aria-describedby="input_7_31_date_format" aria-invalid="false" aria-required="true" disabled="disabled"><img class="ui-datepicker-trigger"
src="https://marcharriganmd.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_7_31_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_7_31" class="gform_hidden" value="https://marcharriganmd.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" disabled="disabled">
</div>
<div id="field_7_32" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_32" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_32">Gender<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_32" id="input_7_32" class="medium gfield_select" aria-required="true" aria-invalid="false" disabled="disabled">
<option value="Male">Male</option>
<option value="Female">Female</option>
<option value="Prefer Not to Answer">Prefer Not to Answer</option>
</select></div>
</div>
<div id="field_7_238" class="gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_238" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_238">Daytime Phone Number<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_238" id="input_7_238" type="tel" value="" class="medium" tabindex="24" aria-required="true" aria-invalid="false" disabled="disabled"></div>
</div>
<fieldset id="field_7_239"
class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_239" data-conditional-logic="hidden" style="display: none;">
<legend class="gfield_label gform-field-label">Is this a cell number?<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_7_239">
<div class="gchoice gchoice_7_239_0">
<input class="gfield-choice-input" name="input_239" type="radio" value="Yes" id="choice_7_239_0" onchange="gformToggleRadioOther( this )" tabindex="25" disabled="disabled">
<label for="choice_7_239_0" id="label_7_239_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_7_239_1">
<input class="gfield-choice-input" name="input_239" type="radio" value="No" id="choice_7_239_1" onchange="gformToggleRadioOther( this )" tabindex="26" disabled="disabled">
<label for="choice_7_239_1" id="label_7_239_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_7_311"
class="gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_311" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_311">Cell Phone Number<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_311" id="input_7_311" type="tel" value="" class="medium" tabindex="27" aria-required="true" aria-invalid="false" disabled="disabled"></div>
</div>
<div id="field_7_33" class="gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_33" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_33">Email<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_33" id="input_7_33" type="email" value="" class="medium" tabindex="28" aria-required="true" aria-invalid="false" disabled="disabled">
</div>
</div>
<div id="field_7_58" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_58"
data-conditional-logic="hidden" style="display: none;">
<h3 class="gsection_title">3rd Individual (27 and over)</h3>
</div>
<fieldset id="field_7_55" class="gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_55" data-conditional-logic="hidden" style="display: none;">
<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_7_55">
<span id="input_7_55_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<label for="input_7_55_3" class="gform-field-label gform-field-label--type-sub ">First</label>
<input type="text" name="input_55.3" id="input_7_55_3" value="" tabindex="30" aria-required="true" disabled="disabled">
</span>
<span id="input_7_55_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<label for="input_7_55_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
<input type="text" name="input_55.6" id="input_7_55_6" value="" tabindex="32" aria-required="true" disabled="disabled">
</span>
</div>
</fieldset>
<div id="field_7_57"
class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_57" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_57">Date of Birth<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_57" id="input_7_57" type="text" value="" class="datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" tabindex="34" placeholder="mm/dd/yyyy"
aria-describedby="input_7_57_date_format" aria-invalid="false" aria-required="true" disabled="disabled"><img class="ui-datepicker-trigger"
src="https://marcharriganmd.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_7_57_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_7_57" class="gform_hidden" value="https://marcharriganmd.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" disabled="disabled">
</div>
<div id="field_7_85" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_85" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_85">Gender<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_85" id="input_7_85" class="medium gfield_select" aria-required="true" aria-invalid="false" disabled="disabled">
<option value="Male">Male</option>
<option value="Female">Female</option>
<option value="Prefer Not to Answer">Prefer Not to Answer</option>
</select></div>
</div>
<div id="field_7_241" class="gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_241" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_241">Daytime Phone Number<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_241" id="input_7_241" type="tel" value="" class="medium" tabindex="36" aria-required="true" aria-invalid="false" disabled="disabled"></div>
</div>
<fieldset id="field_7_242"
class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_242" data-conditional-logic="hidden" style="display: none;">
<legend class="gfield_label gform-field-label">Is this a cell number?<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_7_242">
<div class="gchoice gchoice_7_242_0">
<input class="gfield-choice-input" name="input_242" type="radio" value="Yes" id="choice_7_242_0" onchange="gformToggleRadioOther( this )" tabindex="37" disabled="disabled">
<label for="choice_7_242_0" id="label_7_242_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_7_242_1">
<input class="gfield-choice-input" name="input_242" type="radio" value="No" id="choice_7_242_1" onchange="gformToggleRadioOther( this )" tabindex="38" disabled="disabled">
<label for="choice_7_242_1" id="label_7_242_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_7_312"
class="gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_312" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_312">Cell Phone Number<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_312" id="input_7_312" type="tel" value="" class="medium" tabindex="39" aria-required="true" aria-invalid="false" disabled="disabled"></div>
</div>
<div id="field_7_59" class="gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_59" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_59">Email<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_59" id="input_7_59" type="email" value="" class="medium" tabindex="40" aria-required="true" aria-invalid="false" disabled="disabled">
</div>
</div>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_7_185" class="gform_previous_button gform-theme-button gform-theme-button--secondary button" value="Previous" tabindex="41"
onclick="jQuery("#gform_target_page_number_7").val("1"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("1"); jQuery("#gform_7").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_7_185"
class="gform_next_button gform-theme-button button" value="Next" tabindex="42" onclick="jQuery("#gform_target_page_number_7").val("3"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("3"); jQuery("#gform_7").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_7_3" class="gform_page" data-js="page-field-id-185" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_7_3" class="gform_fields top_label form_sublabel_above description_above validation_below">
<div id="field_7_186" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_186"
data-conditional-logic="hidden" style="display: none;">
<h3 class="gsection_title">1st Individual (between the ages of 12 and 26)</h3>
</div>
<fieldset id="field_7_192" class="gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_192" data-conditional-logic="hidden" style="display: none;">
<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_7_192">
<span id="input_7_192_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<label for="input_7_192_3" class="gform-field-label gform-field-label--type-sub ">First</label>
<input type="text" name="input_192.3" id="input_7_192_3" value="" tabindex="44" aria-required="true" disabled="disabled">
</span>
<span id="input_7_192_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<label for="input_7_192_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
<input type="text" name="input_192.6" id="input_7_192_6" value="" tabindex="46" aria-required="true" disabled="disabled">
</span>
</div>
</fieldset>
<div id="field_7_193"
class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_193" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_193">Date of Birth<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_193" id="input_7_193" type="text" value="" class="datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" tabindex="48" placeholder="mm/dd/yyyy"
aria-describedby="input_7_193_date_format" aria-invalid="false" aria-required="true" disabled="disabled"><img class="ui-datepicker-trigger"
src="https://marcharriganmd.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_7_193_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_7_193" class="gform_hidden" value="https://marcharriganmd.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" disabled="disabled">
</div>
<div id="field_7_194" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_194" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_194">Gender<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_194" id="input_7_194" class="medium gfield_select" aria-required="true" aria-invalid="false" disabled="disabled">
<option value="Male">Male</option>
<option value="Female">Female</option>
<option value="Prefer Not to Answer">Prefer Not to Answer</option>
</select></div>
</div>
<div id="field_7_265" class="gfield gfield--type-phone gfield--input-type-phone field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_265"
data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_265">Daytime Phone Number</label>
<div class="ginput_container ginput_container_phone"><input name="input_265" id="input_7_265" type="tel" value="" class="medium" tabindex="50" aria-invalid="false" disabled="disabled"></div>
</div>
<fieldset id="field_7_266"
class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_266" data-conditional-logic="hidden" style="display: none;">
<legend class="gfield_label gform-field-label">Is this a cell number?<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_7_266">
<div class="gchoice gchoice_7_266_0">
<input class="gfield-choice-input" name="input_266" type="radio" value="Yes" id="choice_7_266_0" onchange="gformToggleRadioOther( this )" tabindex="51" disabled="disabled">
<label for="choice_7_266_0" id="label_7_266_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_7_266_1">
<input class="gfield-choice-input" name="input_266" type="radio" value="No" id="choice_7_266_1" onchange="gformToggleRadioOther( this )" tabindex="52" disabled="disabled">
<label for="choice_7_266_1" id="label_7_266_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_7_316" class="gfield gfield--type-phone gfield--input-type-phone gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_316" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_316">Cell Phone Number</label>
<div class="ginput_container ginput_container_phone"><input name="input_316" id="input_7_316" type="tel" value="" class="medium" tabindex="53" aria-invalid="false" disabled="disabled"></div>
</div>
<div id="field_7_195" class="gfield gfield--type-email gfield--input-type-email field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_195"
data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_195">Email</label>
<div class="ginput_container ginput_container_email">
<input name="input_195" id="input_7_195" type="email" value="" class="medium" tabindex="54" aria-invalid="false" disabled="disabled">
</div>
</div>
<div id="field_7_187" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_187"
data-conditional-logic="hidden" style="display: none;">
<h3 class="gsection_title">2nd Individual (between the ages of 12 and 26)</h3>
</div>
<fieldset id="field_7_196" class="gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_196" data-conditional-logic="hidden" style="display: none;">
<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_7_196">
<span id="input_7_196_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<label for="input_7_196_3" class="gform-field-label gform-field-label--type-sub ">First</label>
<input type="text" name="input_196.3" id="input_7_196_3" value="" tabindex="56" aria-required="true" disabled="disabled">
</span>
<span id="input_7_196_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<label for="input_7_196_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
<input type="text" name="input_196.6" id="input_7_196_6" value="" tabindex="58" aria-required="true" disabled="disabled">
</span>
</div>
</fieldset>
<div id="field_7_197"
class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_197" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_197">Date of Birth<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_197" id="input_7_197" type="text" value="" class="datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" tabindex="60" placeholder="mm/dd/yyyy"
aria-describedby="input_7_197_date_format" aria-invalid="false" aria-required="true" disabled="disabled"><img class="ui-datepicker-trigger"
src="https://marcharriganmd.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_7_197_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_7_197" class="gform_hidden" value="https://marcharriganmd.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" disabled="disabled">
</div>
<div id="field_7_198" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_198" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_198">Gender<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_198" id="input_7_198" class="medium gfield_select" aria-required="true" aria-invalid="false" disabled="disabled">
<option value="Male">Male</option>
<option value="Female">Female</option>
<option value="Prefer Not to Answer">Prefer Not to Answer</option>
</select></div>
</div>
<div id="field_7_267" class="gfield gfield--type-phone gfield--input-type-phone field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_267"
data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_267">Daytime Phone Number</label>
<div class="ginput_container ginput_container_phone"><input name="input_267" id="input_7_267" type="tel" value="" class="medium" tabindex="62" aria-invalid="false" disabled="disabled"></div>
</div>
<fieldset id="field_7_268"
class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_268" data-conditional-logic="hidden" style="display: none;">
<legend class="gfield_label gform-field-label">Is this a cell number?<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_7_268">
<div class="gchoice gchoice_7_268_0">
<input class="gfield-choice-input" name="input_268" type="radio" value="Yes" id="choice_7_268_0" onchange="gformToggleRadioOther( this )" tabindex="63" disabled="disabled">
<label for="choice_7_268_0" id="label_7_268_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_7_268_1">
<input class="gfield-choice-input" name="input_268" type="radio" value="No" id="choice_7_268_1" onchange="gformToggleRadioOther( this )" tabindex="64" disabled="disabled">
<label for="choice_7_268_1" id="label_7_268_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_7_317" class="gfield gfield--type-phone gfield--input-type-phone gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_317" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_317">Cell Phone Number</label>
<div class="ginput_container ginput_container_phone"><input name="input_317" id="input_7_317" type="tel" value="" class="medium" tabindex="65" aria-invalid="false" disabled="disabled"></div>
</div>
<div id="field_7_199" class="gfield gfield--type-email gfield--input-type-email field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_199"
data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_199">Email</label>
<div class="ginput_container ginput_container_email">
<input name="input_199" id="input_7_199" type="email" value="" class="medium" tabindex="66" aria-invalid="false" disabled="disabled">
</div>
</div>
<div id="field_7_188" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_188"
data-conditional-logic="hidden" style="display: none;">
<h3 class="gsection_title">3rd Individual (between the ages of 12 and 26)</h3>
</div>
<fieldset id="field_7_200" class="gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_200" data-conditional-logic="hidden" style="display: none;">
<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_7_200">
<span id="input_7_200_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<label for="input_7_200_3" class="gform-field-label gform-field-label--type-sub ">First</label>
<input type="text" name="input_200.3" id="input_7_200_3" value="" tabindex="68" aria-required="true" disabled="disabled">
</span>
<span id="input_7_200_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<label for="input_7_200_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
<input type="text" name="input_200.6" id="input_7_200_6" value="" tabindex="70" aria-required="true" disabled="disabled">
</span>
</div>
</fieldset>
<div id="field_7_201"
class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_201" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_201">Date of Birth<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_201" id="input_7_201" type="text" value="" class="datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" tabindex="72" placeholder="mm/dd/yyyy"
aria-describedby="input_7_201_date_format" aria-invalid="false" aria-required="true" disabled="disabled"><img class="ui-datepicker-trigger"
src="https://marcharriganmd.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_7_201_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_7_201" class="gform_hidden" value="https://marcharriganmd.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" disabled="disabled">
</div>
<div id="field_7_202" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_202" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_202">Gender<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_202" id="input_7_202" class="medium gfield_select" aria-required="true" aria-invalid="false" disabled="disabled">
<option value="Male">Male</option>
<option value="Female">Female</option>
<option value="Prefer Not to Answer">Prefer Not to Answer</option>
</select></div>
</div>
<div id="field_7_269" class="gfield gfield--type-phone gfield--input-type-phone field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_269"
data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_269">Daytime Phone Number</label>
<div class="ginput_container ginput_container_phone"><input name="input_269" id="input_7_269" type="tel" value="" class="medium" tabindex="74" aria-invalid="false" disabled="disabled"></div>
</div>
<fieldset id="field_7_270"
class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_270" data-conditional-logic="hidden" style="display: none;">
<legend class="gfield_label gform-field-label">Is this a cell number?<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_7_270">
<div class="gchoice gchoice_7_270_0">
<input class="gfield-choice-input" name="input_270" type="radio" value="Yes" id="choice_7_270_0" onchange="gformToggleRadioOther( this )" tabindex="75" disabled="disabled">
<label for="choice_7_270_0" id="label_7_270_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_7_270_1">
<input class="gfield-choice-input" name="input_270" type="radio" value="No" id="choice_7_270_1" onchange="gformToggleRadioOther( this )" tabindex="76" disabled="disabled">
<label for="choice_7_270_1" id="label_7_270_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_7_318" class="gfield gfield--type-phone gfield--input-type-phone gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_318" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_318">Cell Phone Number</label>
<div class="ginput_container ginput_container_phone"><input name="input_318" id="input_7_318" type="tel" value="" class="medium" tabindex="77" aria-invalid="false" disabled="disabled"></div>
</div>
<div id="field_7_203" class="gfield gfield--type-email gfield--input-type-email field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_203"
data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_203">Email</label>
<div class="ginput_container ginput_container_email">
<input name="input_203" id="input_7_203" type="email" value="" class="medium" tabindex="78" aria-invalid="false" disabled="disabled">
</div>
</div>
<div id="field_7_189" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_189"
data-conditional-logic="hidden" style="display: none;">
<h3 class="gsection_title">4th Individual (between the ages of 12 and 26)</h3>
</div>
<fieldset id="field_7_204" class="gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_204" data-conditional-logic="hidden" style="display: none;">
<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_7_204">
<span id="input_7_204_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<label for="input_7_204_3" class="gform-field-label gform-field-label--type-sub ">First</label>
<input type="text" name="input_204.3" id="input_7_204_3" value="" tabindex="80" aria-required="true" disabled="disabled">
</span>
<span id="input_7_204_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<label for="input_7_204_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
<input type="text" name="input_204.6" id="input_7_204_6" value="" tabindex="82" aria-required="true" disabled="disabled">
</span>
</div>
</fieldset>
<div id="field_7_205"
class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_205" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_205">Date of Birth<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_205" id="input_7_205" type="text" value="" class="datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" tabindex="84" placeholder="mm/dd/yyyy"
aria-describedby="input_7_205_date_format" aria-invalid="false" aria-required="true" disabled="disabled"><img class="ui-datepicker-trigger"
src="https://marcharriganmd.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_7_205_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_7_205" class="gform_hidden" value="https://marcharriganmd.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" disabled="disabled">
</div>
<div id="field_7_206" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_206" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_206">Gender<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_206" id="input_7_206" class="medium gfield_select" aria-required="true" aria-invalid="false" disabled="disabled">
<option value="Male">Male</option>
<option value="Female">Female</option>
<option value="Prefer Not to Answer">Prefer Not to Answer</option>
</select></div>
</div>
<div id="field_7_271" class="gfield gfield--type-phone gfield--input-type-phone field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_271"
data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_271">Daytime Phone Number</label>
<div class="ginput_container ginput_container_phone"><input name="input_271" id="input_7_271" type="tel" value="" class="medium" tabindex="86" aria-invalid="false" disabled="disabled"></div>
</div>
<fieldset id="field_7_272"
class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_272" data-conditional-logic="hidden" style="display: none;">
<legend class="gfield_label gform-field-label">Is this a cell number?<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_7_272">
<div class="gchoice gchoice_7_272_0">
<input class="gfield-choice-input" name="input_272" type="radio" value="Yes" id="choice_7_272_0" onchange="gformToggleRadioOther( this )" tabindex="87" disabled="disabled">
<label for="choice_7_272_0" id="label_7_272_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_7_272_1">
<input class="gfield-choice-input" name="input_272" type="radio" value="No" id="choice_7_272_1" onchange="gformToggleRadioOther( this )" tabindex="88" disabled="disabled">
<label for="choice_7_272_1" id="label_7_272_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_7_319" class="gfield gfield--type-phone gfield--input-type-phone gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_319" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_319">Cell Phone Number</label>
<div class="ginput_container ginput_container_phone"><input name="input_319" id="input_7_319" type="tel" value="" class="medium" tabindex="89" aria-invalid="false" disabled="disabled"></div>
</div>
<div id="field_7_207" class="gfield gfield--type-email gfield--input-type-email field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_207"
data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_207">Email</label>
<div class="ginput_container ginput_container_email">
<input name="input_207" id="input_7_207" type="email" value="" class="medium" tabindex="90" aria-invalid="false" disabled="disabled">
</div>
</div>
<div id="field_7_190" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_190"
data-conditional-logic="hidden" style="display: none;">
<h3 class="gsection_title">5th Individual (between the ages of 12 and 26)</h3>
</div>
<fieldset id="field_7_208" class="gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_208" data-conditional-logic="hidden" style="display: none;">
<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_7_208">
<span id="input_7_208_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<label for="input_7_208_3" class="gform-field-label gform-field-label--type-sub ">First</label>
<input type="text" name="input_208.3" id="input_7_208_3" value="" tabindex="92" aria-required="true" disabled="disabled">
</span>
<span id="input_7_208_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<label for="input_7_208_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
<input type="text" name="input_208.6" id="input_7_208_6" value="" tabindex="94" aria-required="true" disabled="disabled">
</span>
</div>
</fieldset>
<div id="field_7_209"
class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_209" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_209">Date of Birth<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_209" id="input_7_209" type="text" value="" class="datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" tabindex="96" placeholder="mm/dd/yyyy"
aria-describedby="input_7_209_date_format" aria-invalid="false" aria-required="true" disabled="disabled"><img class="ui-datepicker-trigger"
src="https://marcharriganmd.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_7_209_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_7_209" class="gform_hidden" value="https://marcharriganmd.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" disabled="disabled">
</div>
<div id="field_7_210" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_210" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_210">Gender<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_210" id="input_7_210" class="medium gfield_select" aria-required="true" aria-invalid="false" disabled="disabled">
<option value="Male">Male</option>
<option value="Female">Female</option>
<option value="Prefer Not to Answer">Prefer Not to Answer</option>
</select></div>
</div>
<div id="field_7_273" class="gfield gfield--type-phone gfield--input-type-phone field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_273"
data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_273">Daytime Phone Number</label>
<div class="ginput_container ginput_container_phone"><input name="input_273" id="input_7_273" type="tel" value="" class="medium" tabindex="98" aria-invalid="false" disabled="disabled"></div>
</div>
<fieldset id="field_7_274"
class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_274" data-conditional-logic="hidden" style="display: none;">
<legend class="gfield_label gform-field-label">Is this a cell number?<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_7_274">
<div class="gchoice gchoice_7_274_0">
<input class="gfield-choice-input" name="input_274" type="radio" value="Yes" id="choice_7_274_0" onchange="gformToggleRadioOther( this )" tabindex="99" disabled="disabled">
<label for="choice_7_274_0" id="label_7_274_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_7_274_1">
<input class="gfield-choice-input" name="input_274" type="radio" value="No" id="choice_7_274_1" onchange="gformToggleRadioOther( this )" tabindex="100" disabled="disabled">
<label for="choice_7_274_1" id="label_7_274_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_7_320" class="gfield gfield--type-phone gfield--input-type-phone gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_320" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_320">Cell Phone Number</label>
<div class="ginput_container ginput_container_phone"><input name="input_320" id="input_7_320" type="tel" value="" class="medium" tabindex="101" aria-invalid="false" disabled="disabled"></div>
</div>
<div id="field_7_211" class="gfield gfield--type-email gfield--input-type-email field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_211"
data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_211">Email</label>
<div class="ginput_container ginput_container_email">
<input name="input_211" id="input_7_211" type="email" value="" class="medium" tabindex="102" aria-invalid="false" disabled="disabled">
</div>
</div>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_7_155" class="gform_previous_button gform-theme-button gform-theme-button--secondary button" value="Previous" tabindex="103"
onclick="jQuery("#gform_target_page_number_7").val("2"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("2"); jQuery("#gform_7").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_7_155"
class="gform_next_button gform-theme-button button" value="Next" tabindex="104" onclick="jQuery("#gform_target_page_number_7").val("4"); jQuery("#gform_7").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_7").val("4"); jQuery("#gform_7").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_7_4" class="gform_page" data-js="page-field-id-155" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_7_4" class="gform_fields top_label form_sublabel_above description_above validation_below">
<fieldset id="field_7_4"
class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_4">
<legend class="gfield_label gform-field-label">Payment Schedule<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_7_4">
<div class="gchoice gchoice_7_4_0">
<input class="gfield-choice-input" name="input_4" type="radio" value="I will pay annually" id="choice_7_4_0" onchange="gformToggleRadioOther( this )" tabindex="105">
<label for="choice_7_4_0" id="label_7_4_0" class="gform-field-label gform-field-label--type-inline">I will pay annually</label>
</div>
<div class="gchoice gchoice_7_4_1">
<input class="gfield-choice-input" name="input_4" type="radio" value="I will pay semianually" id="choice_7_4_1" onchange="gformToggleRadioOther( this )" tabindex="106">
<label for="choice_7_4_1" id="label_7_4_1" class="gform-field-label gform-field-label--type-inline">I will pay semianually</label>
</div>
<div class="gchoice gchoice_7_4_2">
<input class="gfield-choice-input" name="input_4" type="radio" value="I will pay quarterly" id="choice_7_4_2" onchange="gformToggleRadioOther( this )" tabindex="107">
<label for="choice_7_4_2" id="label_7_4_2" class="gform-field-label gform-field-label--type-inline">I will pay quarterly</label>
</div>
</div>
</div>
</fieldset>
<div id="field_7_298"
class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_298" data-conditional-logic="hidden" style="display: none;">
<p>I understand that the full annual fee will be charged <strong>upon receipt of this form</strong> and the full annual fee will be charged <span style="text-decoration: underline;">automatically</span> at 12-month intervals, continually
while this Agreement remains in effect.</p>
</div>
<div id="field_7_299"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_299" data-conditional-logic="hidden" style="display: none;">
<p>I understand that one-half of the full annual fee will be charged <strong>upon receipt of this form</strong> and one-half will be charged <span style="text-decoration: underline;">automatically</span> at six-month intervals,
continually while this Agreement remains in effect.</p>
</div>
<div id="field_7_324"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_324" data-conditional-logic="hidden" style="display: none;">
<p>I understand that one-quarter of the full annual fee will be charged <strong>upon receipt of this form</strong> and one-quarter will be charged <span style="text-decoration: underline;">automatically</span> at three-month intervals,
continually while this Agreement remains in effect.</p>
</div>
<div id="field_7_101" class="gfield gfield--type-number gfield--input-type-number gfield_calculation field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_101" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_101">Your ANNUAL Payment:</label>
<div class="gfield_description" id="gfield_description_7_101">This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged <strong>ANNUALLY</strong>:</div>
<div class="ginput_container ginput_container_number"><input name="input_101" id="input_7_101" type="text" step="any" value="" class="small" tabindex="108" readonly="readonly" aria-invalid="false"
aria-describedby="gfield_description_7_101" disabled="disabled"></div>
</div>
<div id="field_7_102" class="gfield gfield--type-number gfield--input-type-number gfield_calculation field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_102" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_102">Your SEMIANNUAL Payment:</label>
<div class="gfield_description" id="gfield_description_7_102">This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged <strong>SEMIANNUALLY</strong>:</div>
<div class="ginput_container ginput_container_number"><input name="input_102" id="input_7_102" type="text" step="any" value="" class="small" tabindex="109" readonly="readonly" aria-invalid="false"
aria-describedby="gfield_description_7_102" disabled="disabled"></div>
</div>
<div id="field_7_325" class="gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_calculation field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_325" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_325">Your QUARTERLY Payment:</label>
<div class="gfield_description" id="gfield_description_7_325">This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged <strong>QUARTERLY</strong>:</div>
<div class="ginput_container ginput_container_number"><input name="input_325" id="input_7_325" type="text" step="any" value="" class="small" tabindex="110" readonly="readonly" aria-invalid="false"
aria-describedby="gfield_description_7_325" disabled="disabled"></div>
</div>
<div id="field_7_295" class="gfield gfield--type-select gfield--input-type-select payment-method-radio field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_hidden"
data-js-reload="field_7_295">
<div class="admin-hidden-markup"><i class="gform-icon gform-icon--hidden"></i><span>Hidden</span></div><label class="gfield_label gform-field-label" for="input_7_295">Payment Method</label>
<div class="ginput_container ginput_container_select"><select name="input_295" id="input_7_295" class="medium gfield_select" tabindex="111" aria-invalid="false">
<option value="credit card" selected="selected">credit card</option>
<option value="ACH">ACH</option>
</select></div>
</div>
<div id="field_7_157" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_157">
<h3 class="gsection_title">Credit Card Details</h3>
</div>
<div id="field_7_309"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_309">
<p>Your card will be charged by HMCS</p>
</div>
<fieldset id="field_7_287"
class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_287">
<legend class="gfield_label gform-field-label">Credit Card Type<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_7_287">
<div class="gchoice gchoice_7_287_0">
<input class="gfield-choice-input" name="input_287" type="radio" value="Visa" id="choice_7_287_0" onchange="gformToggleRadioOther( this )" tabindex="112">
<label for="choice_7_287_0" id="label_7_287_0" class="gform-field-label gform-field-label--type-inline">Visa</label>
</div>
<div class="gchoice gchoice_7_287_1">
<input class="gfield-choice-input" name="input_287" type="radio" value="MasterCard" id="choice_7_287_1" onchange="gformToggleRadioOther( this )" tabindex="113">
<label for="choice_7_287_1" id="label_7_287_1" class="gform-field-label gform-field-label--type-inline">MasterCard</label>
</div>
<div class="gchoice gchoice_7_287_2">
<input class="gfield-choice-input" name="input_287" type="radio" value="AMEX" id="choice_7_287_2" onchange="gformToggleRadioOther( this )" tabindex="114">
<label for="choice_7_287_2" id="label_7_287_2" class="gform-field-label gform-field-label--type-inline">AMEX</label>
</div>
<div class="gchoice gchoice_7_287_3">
<input class="gfield-choice-input" name="input_287" type="radio" value="Discover" id="choice_7_287_3" onchange="gformToggleRadioOther( this )" tabindex="115">
<label for="choice_7_287_3" id="label_7_287_3" class="gform-field-label gform-field-label--type-inline">Discover</label>
</div>
</div>
</div>
</fieldset>
<div id="field_7_288" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_288" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_288">Card 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_288" id="input_7_288" type="text" value="" class="medium" tabindex="116" aria-required="true" aria-invalid="false" disabled="disabled"> </div>
</div>
<div id="field_7_289" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_289" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_289">Card 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_289" id="input_7_289" type="text" value="" class="medium" tabindex="117" aria-required="true" aria-invalid="false" disabled="disabled"> </div>
</div>
<div id="field_7_305" class="gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_305"><label class="gfield_label gform-field-label" for="input_7_305">Expiration Month</label>
<div class="ginput_container ginput_container_select"><select name="input_305" id="input_7_305" class="medium gfield_select" tabindex="118" aria-invalid="false">
<option value="01">January</option>
<option value="02">February</option>
<option value="03">March</option>
<option value="04">April</option>
<option value="05">May</option>
<option value="06">June</option>
<option value="07">July</option>
<option value="08">August</option>
<option value="09">September</option>
<option value="10">October</option>
<option value="11">November</option>
<option value="12">December</option>
</select></div>
</div>
<div id="field_7_306" class="gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_306"><label class="gfield_label gform-field-label" for="input_7_306">Expiration Year</label>
<div class="ginput_container ginput_container_select"><select name="input_306" id="input_7_306" class="medium gfield_select" tabindex="119" aria-invalid="false">
<option value="23">2023</option>
<option value="24">2024</option>
<option value="25">2025</option>
<option value="26">2026</option>
<option value="27">2027</option>
<option value="28">2028</option>
<option value="29">2029</option>
<option value="30">2030</option>
<option value="31">2031</option>
<option value="32">2032</option>
<option value="33">2033</option>
<option value="34">2034</option>
<option value="35">2035</option>
<option value="36">2036</option>
<option value="37">2037</option>
<option value="38">2038</option>
<option value="39">2039</option>
<option value="40">2040</option>
<option value="41">2041</option>
<option value="42">2042</option>
<option value="43">2043</option>
<option value="44">2044</option>
<option value="45">2045</option>
<option value="46">2046</option>
<option value="47">2047</option>
<option value="48">2048</option>
<option value="49">2049</option>
<option value="50">2050</option>
<option value=""></option>
</select></div>
</div>
<div id="field_7_292" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_292" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_292">Security Code<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_292" id="input_7_292" type="text" value="" class="medium" tabindex="120" aria-required="true" aria-invalid="false" disabled="disabled"> </div>
</div>
<div id="field_7_293" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_293" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_293">Security Code<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_293" id="input_7_293" type="text" value="" class="medium" tabindex="121" aria-required="true" aria-invalid="false" disabled="disabled"> </div>
</div>
<div id="field_7_294" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_294"><label class="gfield_label gform-field-label" for="input_7_294">Cardholder Name<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_294" id="input_7_294" type="text" value="" class="medium" tabindex="122" aria-required="true" aria-invalid="false"> </div>
</div>
<fieldset id="field_7_115" class="gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_115">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Billing Address<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row" id="input_7_115">
<span class="ginput_full address_line_1 ginput_address_line_1 gform-grid-col" id="input_7_115_1_container">
<label for="input_7_115_1" id="input_7_115_1_label" class="gform-field-label gform-field-label--type-sub ">Street Address</label>
<input type="text" name="input_115.1" id="input_7_115_1" value="" tabindex="123" aria-required="true">
</span><span class="ginput_full address_line_2 ginput_address_line_2 gform-grid-col" id="input_7_115_2_container">
<label for="input_7_115_2" id="input_7_115_2_label" class="gform-field-label gform-field-label--type-sub ">Address Line 2</label>
<input type="text" name="input_115.2" id="input_7_115_2" value="" tabindex="124" aria-required="false">
</span><span class="ginput_left address_city ginput_address_city gform-grid-col" id="input_7_115_3_container">
<label for="input_7_115_3" id="input_7_115_3_label" class="gform-field-label gform-field-label--type-sub ">City</label>
<input type="text" name="input_115.3" id="input_7_115_3" value="" tabindex="125" aria-required="true">
</span><span class="ginput_right address_state ginput_address_state gform-grid-col" id="input_7_115_4_container">
<label for="input_7_115_4" id="input_7_115_4_label" class="gform-field-label gform-field-label--type-sub ">State</label>
<select name="input_115.4" id="input_7_115_4" tabindex="126" aria-required="true">
<option value="" selected="selected"></option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="American Samoa">American Samoa</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Guam">Guam</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="U.S. Virgin Islands">U.S. Virgin Islands</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
<option value="Armed Forces Americas">Armed Forces Americas</option>
<option value="Armed Forces Europe">Armed Forces Europe</option>
<option value="Armed Forces Pacific">Armed Forces Pacific</option>
</select>
</span><span class="ginput_left address_zip ginput_address_zip gform-grid-col" id="input_7_115_5_container">
<label for="input_7_115_5" id="input_7_115_5_label" class="gform-field-label gform-field-label--type-sub ">ZIP Code</label>
<input type="text" name="input_115.5" id="input_7_115_5" value="" tabindex="128" aria-required="true">
</span><input type="hidden" class="gform_hidden" name="input_115.6" id="input_7_115_6" value="United States">
<div class="gf_clear gf_clear_complex"></div>
</div>
</fieldset>
<div id="field_7_113" class="gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_113"><label class="gfield_label gform-field-label" for="input_7_113">Daytime Phone Number<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_113" id="input_7_113" type="tel" value="" class="medium" tabindex="129" aria-required="true" aria-invalid="false"></div>
</div>
<fieldset id="field_7_119"
class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_119">
<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_checkbox">
<div class="gfield_checkbox" id="input_7_119">
<div class="gchoice gchoice_7_119_1">
<input class="gfield-choice-input" name="input_119.1" type="checkbox" value="I authorize HMCS to automatically charge my credit card the amount(s) indicated on this form." id="choice_7_119_1" tabindex="130">
<label for="choice_7_119_1" id="label_7_119_1" class="gform-field-label gform-field-label--type-inline">I authorize HMCS to automatically charge my credit card the amount(s) indicated on this form.</label>
</div>
</div>
</div>
</fieldset>
<div id="field_7_158" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_158"
data-conditional-logic="hidden" style="display: none;">
<h3 class="gsection_title">ACH Option</h3>
</div>
<fieldset id="field_7_56" class="gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_56" data-conditional-logic="hidden" style="display: none;">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Billing Address<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row" id="input_7_56">
<span class="ginput_full address_line_1 ginput_address_line_1 gform-grid-col" id="input_7_56_1_container">
<label for="input_7_56_1" id="input_7_56_1_label" class="gform-field-label gform-field-label--type-sub ">Street Address</label>
<input type="text" name="input_56.1" id="input_7_56_1" value="" tabindex="131" aria-required="true" disabled="disabled">
</span><span class="ginput_full address_line_2 ginput_address_line_2 gform-grid-col" id="input_7_56_2_container">
<label for="input_7_56_2" id="input_7_56_2_label" class="gform-field-label gform-field-label--type-sub ">Address Line 2</label>
<input type="text" name="input_56.2" id="input_7_56_2" value="" tabindex="132" aria-required="false" disabled="disabled">
</span><span class="ginput_left address_city ginput_address_city gform-grid-col" id="input_7_56_3_container">
<label for="input_7_56_3" id="input_7_56_3_label" class="gform-field-label gform-field-label--type-sub ">City</label>
<input type="text" name="input_56.3" id="input_7_56_3" value="" tabindex="133" aria-required="true" disabled="disabled">
</span><span class="ginput_right address_state ginput_address_state gform-grid-col" id="input_7_56_4_container">
<label for="input_7_56_4" id="input_7_56_4_label" class="gform-field-label gform-field-label--type-sub ">State</label>
<select name="input_56.4" id="input_7_56_4" aria-required="true" disabled="disabled">
<option value="" selected="selected"></option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="American Samoa">American Samoa</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Guam">Guam</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="U.S. Virgin Islands">U.S. Virgin Islands</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
<option value="Armed Forces Americas">Armed Forces Americas</option>
<option value="Armed Forces Europe">Armed Forces Europe</option>
<option value="Armed Forces Pacific">Armed Forces Pacific</option>
</select>
</span><span class="ginput_left address_zip ginput_address_zip gform-grid-col" id="input_7_56_5_container">
<label for="input_7_56_5" id="input_7_56_5_label" class="gform-field-label gform-field-label--type-sub ">ZIP Code</label>
<input type="text" name="input_56.5" id="input_7_56_5" value="" tabindex="136" aria-required="true" disabled="disabled">
</span><input type="hidden" class="gform_hidden" name="input_56.6" id="input_7_56_6" value="United States" disabled="disabled">
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data-js-reload="field_7_83" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_83">Daytime Phone Number<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_83" id="input_7_83" type="tel" value="" class="medium" tabindex="137" aria-required="true" aria-invalid="false" disabled="disabled"></div>
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data-js-reload="field_7_122" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_122">Bank Name<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_122" id="input_7_122" type="text" value="" class="medium" tabindex="138" aria-required="true" aria-invalid="false" disabled="disabled"> </div>
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<div id="field_7_162" class="gfield gfield--type-select gfield--input-type-select field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_7_162"
data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_162">Account Type</label>
<div class="ginput_container ginput_container_select"><select name="input_162" id="input_7_162" class="medium gfield_select" aria-invalid="false" disabled="disabled">
<option value="Business">Business</option>
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data-js-reload="field_7_116" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_116">Routing 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_116" id="input_7_116" type="text" value="" class="medium" maxlength="9" tabindex="140" aria-required="true" aria-invalid="false" disabled="disabled">
<div class="charleft ginput_counter gfield_description warningTextareaInfo" aria-live="polite">0 of 9 max characters</div>
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</div>
<div id="field_7_123" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_123" data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_7_123">Please Confirm Your Routing 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_123" id="input_7_123" type="text" value="" class="medium" maxlength="9" tabindex="141" aria-required="true" aria-invalid="false" disabled="disabled">
<div class="charleft ginput_counter gfield_description warningTextareaInfo" aria-live="polite">0 of 9 max characters</div>
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<div class="ginput_container ginput_container_text"><input name="input_117" id="input_7_117" type="text" value="" class="medium" tabindex="142" aria-required="true" aria-invalid="false" disabled="disabled"> </div>
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class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_124" id="input_7_124" type="text" value="" class="medium" tabindex="143" aria-required="true" aria-invalid="false" disabled="disabled"> </div>
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<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_checkbox">
<div class="gfield_checkbox" id="input_7_118">
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<label for="choice_7_118_1" id="label_7_118_1" class="gform-field-label gform-field-label--type-inline">I authorize HMCS to automatically pull from my bank account the amount(s) indicated on this form.</label>
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<div id="field_7_28" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible"
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<div class="gfield_description" id="gfield_description_7_28">Please type your initials to confirm this agreement.</div>
<div class="ginput_container ginput_container_text"><input name="input_28" id="input_7_28" type="text" value="" class="medium" aria-describedby="gfield_description_7_28" tabindex="147" aria-required="true" aria-invalid="false"> </div>
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<legend class="gfield_label gform-field-label">Is the home address different from billing address<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_7_25">
<div class="gchoice gchoice_7_25_0">
<input class="gfield-choice-input" name="input_25" type="radio" value="Yes" id="choice_7_25_0" onchange="gformToggleRadioOther( this )" tabindex="148">
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<legend class="gfield_label gform-field-label gfield_label_before_complex">Home Address<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row" id="input_7_24">
<span class="ginput_full address_line_1 ginput_address_line_1 gform-grid-col" id="input_7_24_1_container">
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<label for="input_7_24_3" id="input_7_24_3_label" class="gform-field-label gform-field-label--type-sub ">City</label>
<input type="text" name="input_24.3" id="input_7_24_3" value="" tabindex="152" aria-required="true" disabled="disabled">
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<label for="input_7_24_4" id="input_7_24_4_label" class="gform-field-label gform-field-label--type-sub ">State</label>
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<option value=""></option>
<option value="Alabama">Alabama</option>
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<option value="American Samoa">American Samoa</option>
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<option value="Arkansas">Arkansas</option>
<option value="California" selected="selected">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Guam">Guam</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="U.S. Virgin Islands">U.S. Virgin Islands</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
<option value="Armed Forces Americas">Armed Forces Americas</option>
<option value="Armed Forces Europe">Armed Forces Europe</option>
<option value="Armed Forces Pacific">Armed Forces Pacific</option>
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<input type="text" name="input_24.5" id="input_7_24_5" value="" tabindex="155" aria-required="true" disabled="disabled">
</span><input type="hidden" class="gform_hidden" name="input_24.6" id="input_7_24_6" value="United States" disabled="disabled">
<div class="gf_clear gf_clear_complex"></div>
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<div id="field_7_92" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_7_92"><label class="gfield_label gform-field-label" for="input_7_92">How did you hear about our practice?<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_92" id="input_7_92" class="medium gfield_select" tabindex="156" aria-required="true" aria-invalid="false">
<option value="I am a Current Patient">I am a Current Patient</option>
<option value="I am a Former Patient">I am a Former Patient</option>
<option value="Insurance Provider">Insurance Provider</option>
<option value="Internet Search">Internet Search</option>
<option value="Patient Referral">Patient Referral</option>
<option value="Physician Referral">Physician Referral</option>
<option value="Print Advertising">Print Advertising</option>
<option value="Other">Other</option>
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class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_326" id="input_7_326" class="textarea large" tabindex="157" aria-required="true" aria-invalid="false" rows="10" cols="50" disabled="disabled"></textarea></div>
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<p style="display: none !important;" class="akismet-fields-container" data-prefix="ak_"><label>Δ<textarea name="ak_hp_textarea" cols="45" rows="8" maxlength="100"></textarea></label><input type="hidden" id="ak_js_1" name="ak_js"
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</form>Text Content
NORTHWEST MEDICAL CENTER 3280 HOWELL MILL ROAD NW, SUITE 207 ATLANTA, GA 30327 New Membership Inquiries678-883-5111 Current Member Patients404-355-7055 Medical Payment Portal Concierge Membership Portal * Home * About * Meet Dr. Harrigan * About Concierge Medicine * Benefits of Concierge Medicine * FAQ * The Clinic * For Employers * Health News * Patient Forms * COVID-19 Resources * Visit CDC.gov * Visit Johns Hopkins Website * Contact PATIENT AGREEMENT MARC HARRIGAN, MD Online Enrollment with Credit Card Payment Only Step 1 of 3 - Agreement 33% I have engaged Harrigan Medical Consulting Services, Inc. (HMCS), dba Concierge Medicine of Buckhead, to provide non-covered, non-clinical amenities and benefits to me for an initial period of one year beginning October 28, 2024. I understand that this Agreement will renew automatically following the end of each one-year period unless I provide the Company with a written notice of non- renewal at least 30 days before the end of a Service Year. I further understand that I will be required to pay a yearly membership fee at the start of each renewal term for these non-covered services, amenities, and benefits. As used in this Agreement, the term “Service Year” refers to the one-year period beginning on October 28, 2024, as well as every one-year renewal period thereafter. * $2,500/year = Individual * $4,500/year = Couple * No charge for children of member (ages 12 up to 26 as of date of enrollment) Individuals (27 and over) 0123 Individuals (between the ages of 12 and 26) 012345 Hidden Total members (will be hidden, for logic only) Individuals (27 and over) Price: $0.00 Couples Discount Applied for the first additional adult over the age of 27. Price: -$500.00 Dependents Price: $0.00 Total This Agreement is for non-covered primary care services and other amenities and benefits as described in the Highlights & Details document. I have read and understand this Agreement as well as the Highlights & Details (H&Ds) and Frequently Asked Questions (FAQs) materials provided to me by HMCS. I understand that this Agreement can be terminated upon 30 days written notice. If the agreement is terminated, I may receive a refund of the pro-rated portion of the paid annual fee, based on the number of days that have elapsed in the Service Year, to be determined by HMCS, on a case-by-case basis. Such refund will be paid to me within 30 days after termination. This Agreement will automatically renew for subsequent Service Years under the same payment terms unless I notify HMCS otherwise (or HMCS notifies me) within 30 days of the next payment due date. 1ST INDIVIDUAL (27 AND OVER) Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required) MaleFemalePrefer Not to Answer Daytime Phone Number(Required) Is this a cell number?(Required) Yes No Cell Phone Number(Required) Email(Required) 2ND INDIVIDUAL (27 AND OVER) Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required) MaleFemalePrefer Not to Answer Daytime Phone Number(Required) Is this a cell number?(Required) Yes No Cell Phone Number(Required) Email(Required) 3RD INDIVIDUAL (27 AND OVER) Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required) MaleFemalePrefer Not to Answer Daytime Phone Number(Required) Is this a cell number?(Required) Yes No Cell Phone Number(Required) Email(Required) 1ST INDIVIDUAL (BETWEEN THE AGES OF 12 AND 26) Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required) MaleFemalePrefer Not to Answer Daytime Phone Number Is this a cell number?(Required) Yes No Cell Phone Number Email 2ND INDIVIDUAL (BETWEEN THE AGES OF 12 AND 26) Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required) MaleFemalePrefer Not to Answer Daytime Phone Number Is this a cell number?(Required) Yes No Cell Phone Number Email 3RD INDIVIDUAL (BETWEEN THE AGES OF 12 AND 26) Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required) MaleFemalePrefer Not to Answer Daytime Phone Number Is this a cell number?(Required) Yes No Cell Phone Number Email 4TH INDIVIDUAL (BETWEEN THE AGES OF 12 AND 26) Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required) MaleFemalePrefer Not to Answer Daytime Phone Number Is this a cell number?(Required) Yes No Cell Phone Number Email 5TH INDIVIDUAL (BETWEEN THE AGES OF 12 AND 26) Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required) MaleFemalePrefer Not to Answer Daytime Phone Number Is this a cell number?(Required) Yes No Cell Phone Number Email Payment Schedule(Required) I will pay annually I will pay semianually I will pay quarterly I understand that the full annual fee will be charged upon receipt of this form and the full annual fee will be charged automatically at 12-month intervals, continually while this Agreement remains in effect. I understand that one-half of the full annual fee will be charged upon receipt of this form and one-half will be charged automatically at six-month intervals, continually while this Agreement remains in effect. I understand that one-quarter of the full annual fee will be charged upon receipt of this form and one-quarter will be charged automatically at three-month intervals, continually while this Agreement remains in effect. Your ANNUAL Payment: This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged ANNUALLY: Your SEMIANNUAL Payment: This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged SEMIANNUALLY: Your QUARTERLY Payment: This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged QUARTERLY: Hidden Payment Method credit cardACH CREDIT CARD DETAILS Your card will be charged by HMCS Credit Card Type(Required) Visa MasterCard AMEX Discover Card Number(Required) Card Number(Required) Expiration Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Expiration Year 2023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Security Code(Required) Security Code(Required) Cardholder Name(Required) Billing Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Daytime Phone Number(Required) Consent(Required) I authorize HMCS to automatically charge my credit card the amount(s) indicated on this form. ACH OPTION Billing Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Daytime Phone Number(Required) Bank Name(Required) Account Type BusinessPersonal Routing Number(Required) 0 of 9 max characters Please Confirm Your Routing Number(Required) 0 of 9 max characters Account Number(Required) Please Confirm Your Account Number(Required) Consent(Required) I authorize HMCS to automatically pull from my bank account the amount(s) indicated on this form. Digital Signature(Required) Please type your initials to confirm this agreement. Is the home address different from billing address(Required) Yes No Home Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code How did you hear about our practice?(Required) I am a Current PatientI am a Former PatientInsurance ProviderInternet SearchPatient ReferralPhysician ReferralPrint AdvertisingOther Please elaborate(Required) Δ -------------------------------------------------------------------------------- If you have further questions, please call our Patient Information Line at 678-883-5111. 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