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panel-first-child panel-last-child" data-index="0" ><h3 class="widget-title">Medication Input Form</h3> <script type="text/javascript"> if( window['jQuery'] ) { ( function( $ ) { $( document ).bind( 'gform_post_render', function() { var $firstError = $( 'li.gfield.gfield_error:first' ); if( $firstError.length > 0 ) { $firstError.find( 'input, select, textarea' ).eq( 0 ).focus(); document.body.scrollTop = $firstError.offset().top; } } ); } )( jQuery ); } </script> <script type="text/javascript"></script> <div class='gf_browser_ie gf_browser_ie7 gform_wrapper gravity-theme' id='gform_wrapper_5' style='display:none'><form method='post' enctype='multipart/form-data' id='gform_5' action='/meds/' > <div class='gform_body gform-body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below'><div id="field_5_2" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_5_2' >This form is being submitted for:<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_5_2' type='text' value='' class='large' tabindex='1' placeholder='Full Name' aria-required="true" aria-invalid="false" /> </div></div><div id="field_5_3" class="gfield field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_5_3' >Email</label><div class='ginput_container ginput_container_email'> <input name='input_3' id='input_5_3' type='text' value='' class='large' tabindex='2' aria-invalid="false" /> </div></div><fieldset id="field_5_60" class="gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible" ><legend class='gfield_label' >Do you currently take any prescription medications?</legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_60'> <div class='gchoice gchoice_5_60_0'> <input class='gfield-choice-input' name='input_60' type='radio' value='Yes' id='choice_5_60_0' onchange='gformToggleRadioOther( this )' tabindex='3' /> <label for='choice_5_60_0' id='label_5_60_0'>Yes</label> </div> <div class='gchoice gchoice_5_60_1'> <input class='gfield-choice-input' name='input_60' type='radio' value='No' id='choice_5_60_1' onchange='gformToggleRadioOther( this )' tabindex='4' /> <label for='choice_5_60_1' id='label_5_60_1'>No</label> </div></div></div></fieldset><fieldset id="field_5_58" class="gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible" ><legend class='gfield_label gfield_label_before_complex' >Please list all current prescription medications as listed on your medication bottles. List only medications prescribed by your doctor. Exclude over-the-counter items. Please list the generic name if you take generic medications. If you are taking injectables / inhalers / eyedrops / cremes, please list the number of vials / inhalers / bottles / tubes you use per month.</legend><div class='ginput_container ginput_container_list ginput_list'><div class='gfield_list gfield_list_container'><div class="gfield_list_header"><div class="gfield_header_item">RX Name</div><div class="gfield_header_item">RX Type (Brand or Generic)</div><div class="gfield_header_item">Dosage</div><div class="gfield_header_item">How Often?</div><div class="gfield_header_item"> </div></div><div class="gfield_list_groups"><div class='gfield_list_row_odd gfield_list_group'><div class='gfield_list_group_item gfield_list_cell gfield_list_58_cell1' data-label='RX Name'><input aria-invalid='false' aria-describedby="gfield_description_5_58" aria-label='RX Name, Row 1' data-aria-label-template='RX Name, Row {0}' type='text' name='input_58[]' value='' tabindex='5' /></div><div class='gfield_list_group_item gfield_list_cell gfield_list_58_cell2' data-label='RX Type (Brand or Generic)'><input aria-invalid='false' aria-describedby="gfield_description_5_58" aria-label='RX Type (Brand or Generic), Row 1' data-aria-label-template='RX Type (Brand or Generic), Row {0}' type='text' name='input_58[]' value='' tabindex='6' /></div><div class='gfield_list_group_item gfield_list_cell gfield_list_58_cell3' data-label='Dosage'><input aria-invalid='false' aria-describedby="gfield_description_5_58" aria-label='Dosage, Row 1' data-aria-label-template='Dosage, Row {0}' type='text' name='input_58[]' value='' tabindex='7' /></div><div class='gfield_list_group_item gfield_list_cell gfield_list_58_cell4' data-label='How Often?'><input aria-invalid='false' aria-describedby="gfield_description_5_58" aria-label='How Often?, Row 1' data-aria-label-template='How Often?, Row {0}' type='text' name='input_58[]' value='' tabindex='8' /></div><div class='gfield_list_icons'> <button type="button" class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 25)'>Add</button> <button type="button" class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 25)' style="visibility:hidden;">Remove</button></div></div></div></div></div><div class='gfield_description' id='gfield_description_5_58'>(Click ⊕ at end of row to enter additional medications)</div></fieldset><div id="field_5_45" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" ><h3 class="gsection_title">Pharmacy Information</h3></div><div id="field_5_46" class="gfield gfield--width-full gf_left_half gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_5_46' >Preferred Pharmacy<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_5_46' type='text' value='' class='large' tabindex='9' aria-required="true" aria-invalid="false" /> </div></div><fieldset id="field_5_47" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><legend class='gfield_label gfield_label_before_complex' >Would you be willing to use a different pharmacy if it saves you money?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_47'><div class='gchoice gchoice_5_47_1'> <input class='gfield-choice-input' name='input_47.1' type='checkbox' value='Yes' id='choice_5_47_1' tabindex='10' /> <label for='choice_5_47_1' id='label_5_47_1'>Yes</label> </div><div class='gchoice gchoice_5_47_2'> <input class='gfield-choice-input' name='input_47.2' type='checkbox' value='No' id='choice_5_47_2' tabindex='11' /> <label for='choice_5_47_2' id='label_5_47_2'>No</label> </div></div></div></fieldset><fieldset id="field_5_57" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><legend class='gfield_label gfield_label_before_complex' >Consent<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_consent'><input name='input_57.1' id='input_5_57_1' type='checkbox' value='1' tabindex='12' aria-required="true" aria-invalid="false" /> <label class="gfield_consent_label" for='input_5_57_1' >By checking this box, I have willingly provided the health information on this page to Seniormark, LLC, to assist in my selection of an individual health plan. I am seeking their recommendation for a Medicare plan that will meet my needs. By providing this information, I agree that an authorized representative or licensed insurance agent/producer may contact me by phone, e-mail, or mail to answer my questions or provide additional information about Medicare Supplement Insurance, Medicare Advantage, or Part D plans. I understand the information on this form is not to be used for any purpose other than to assist in my Medicare health plan selection, I am not bound to accept their recommendation, and this service is offered at no cost to me. This authorization expires 120 days after my signature date.</label><input type='hidden' name='input_57.2' value='By checking this box, I have willingly provided the health information on this page to Seniormark, LLC, to assist in my selection of an individual health plan. I am seeking their recommendation for a Medicare plan that will meet my needs. By providing this information, I agree that an authorized representative or licensed insurance agent/producer may contact me by phone, e-mail, or mail to answer my questions or provide additional information about Medicare Supplement Insurance, Medicare Advantage, or Part D plans. I understand the information on this form is not to be used for any purpose other than to assist in my Medicare health plan selection, I am not bound to accept their recommendation, and this service is offered at no cost to me. 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