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448 lines
23 KiB
448 lines
23 KiB
<!DOCTYPE html>
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<html lang="en">
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<head>
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<meta charset="utf-8"/>
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<!-- Main SEO Description -->
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<title>Example Form</title>
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<meta name="description" content="" />
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<meta name="keywords" content="" />
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<!-- Mobile Meta Tags-->
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<meta name="HandheldFriendly" content="true" />
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<meta name="MobileOptimized" content="320" />
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<meta name="Viewport" content="width=device-width" />
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<!-- Author -->
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<meta name="author" content="Rick Hays <rhays@cmpkc.com>" />
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<meta name="creation-date" content="03/15/2013" />
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<link href="css/Normalize-2.1.0.css" rel="stylesheet" type="text/css"/>
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<link href="css/default.css" rel="stylesheet" type="text/css"/>
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<!-- HTML5 shim, for IE6-8 support of HTML elements -->
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<!--[if lt IE 9]><script src="js/html5-shiv.js"></script><![end if]-->
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<!-- jQuery Support -->
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<script src="jquery/jquery-1.9.1.min.js"></script>
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<script>
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$(document).ready(function()
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{
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////////////////////////////
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// Setup State combo boxes /
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////////////////////////////////////////////////////////////////////////////////////////////////////////
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var States = [{text:'AK',value:'AK'},{text:'AL',value:'AL'},{text:'AR',value:'AR'},{text:'AZ',value:'AZ'},{text:'CA',value:'CA'},{text:'CO',value:'CO'},{text:'CT',value:'CT'},{text:'DC',value:'DC'},{text:'DE',value:'DE'},{text:'FL',value:'FL'},{text:'GA',value:'GA'},{text:'HI',value:'HI'},{text:'IA',value:'IA'},{text:'ID',value:'ID'},{text:'IL',value:'IL'},{text:'IN',value:'IN'},{text:'KS',value:'KS'},{text:'KY',value:'KY'},{text:'LA',value:'LA'},{text:'MA',value:'MA'},{text:'MD',value:'MD'},{text:'ME',value:'ME'},{text:'MI',value:'MI'},{text:'MN',value:'MN'},{text:'MO',value:'MO'},{text:'MS',value:'MS'},{text:'MT',value:'MT'},{text:'NC',value:'NC'},{text:'ND',value:'ND'},{text:'NE',value:'NE'},{text:'NH',value:'NH'},{text:'NJ',value:'NJ'},{text:'NM',value:'NM'},{text:'NV',value:'NV'},{text:'NY',value:'NY'},{text:'OH',value:'OH'},{text:'OK',value:'OK'},{text:'OR',value:'OR'},{text:'PA',value:'PA'},{text:'RI',value:'RI'},{text:'SC',value:'SC'},{text:'SD',value:'SD'},{text:'TN',value:'TN'},{text:'TX',value:'TX'},{text:'UT',value:'UT'},{text:'VA',value:'VA'},{text:'VT',value:'VT'},{text:'WA',value:'WA'},{text:'WI',value:'WI'},{text:'WV',value:'WV'},{text:'WY',value:'WY'}];
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$.each(States, function(i, el) { $('#state').append('<option value="'+el.value+'">'+el.text+'</option>');});
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//////////////////////////
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// Setup DOB combo boxes /
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////////////////////////////////////////////////////////////////////////////////////////////////////////
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var today = new Date();
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var today_dd = today.getDate();
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var today_mm = today.getMonth()+1; //January is 0!
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var today_yyyy = today.getFullYear();
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var i;
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function daysInMonth(month, year)
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{
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return new Date(year, month, 0).getDate();
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}
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// Setup Months of Year in combo boxes below.
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for(i=1; i<13; i++)
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{
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var strMonths = (i<10?"0"+i.toString():i.toString());
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$('#dob-mm').append('<option value="'+strMonths+'">'+strMonths+'</option>');
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$('#child1-dob-mm').append('<option value="'+strMonths+'">'+strMonths+'</option>');
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$('#child2-dob-mm').append('<option value="'+strMonths+'">'+strMonths+'</option>');
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$('#child3-dob-mm').append('<option value="'+strMonths+'">'+strMonths+'</option>');
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$('#child4-dob-mm').append('<option value="'+strMonths+'">'+strMonths+'</option>');
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}
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// Setup Days of Month in combo boxes below.
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var Monthdays = daysInMonth(today_mm,today_yyyy)
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for(i=1; i<Monthdays+1; i++)
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{
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var strDays = (i<10?"0"+ i.toString(): i.toString());
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$('#dob-dd').append('<option value="'+strDays+'">'+strDays+'</option>');
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$('#child1-dob-dd').append('<option value="'+strDays+'">'+strDays+'</option>');
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$('#child2-dob-dd').append('<option value="'+strDays+'">'+strDays+'</option>');
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$('#child3-dob-dd').append('<option value="'+strDays+'">'+strDays+'</option>');
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$('#child4-dob-dd').append('<option value="'+strDays+'">'+strDays+'</option>');
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}
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// Setup Years in combo boxes below.
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for(i=today_yyyy-100; i<today_yyyy+1; i++)
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{
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var strYears = i.toString();
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$('#dob-yyyy').append('<option value="'+strYears+'">'+strYears+'</option>');
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$('#child1-dob-yyyy').append('<option value="'+strYears+'">'+strYears+'</option>');
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$('#child2-dob-yyyy').append('<option value="'+strYears+'">'+strYears+'</option>');
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$('#child3-dob-yyyy').append('<option value="'+strYears+'">'+strYears+'</option>');
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$('#child4-dob-yyyy').append('<option value="'+strYears+'">'+strYears+'</option>');
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}
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// Month Event for DOB to reset Days to correct count for month selected.
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$("#dob-mm").change(function()
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{
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var mm = $('#dob-mm').val();
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var yyyy = $('#dob-yyyy').val();
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// Clear Combo box before load
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$('#dob-dd').empty();
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// Add Blank dd to the beginning
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$('#dob-dd').append('<option value="">dd</option>');
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var Monthdays = daysInMonth(mm,yyyy);
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for(i=1; i<Monthdays+1; i++)
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{
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var strDays = (i<10?"0"+ i.toString(): i.toString());
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$('#dob-dd').append('<option value="'+strDays+'">'+strDays+'</option>');
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}
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});
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// Month Event for CHILD1-DOB to reset Days to correct count for month selected.
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$("#child1-dob-mm").change(function()
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{
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var mm = $('#child1-dob-mm').val();
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var yyyy = $('#child1-dob-yyyy').val();
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// Clear Combo box before load
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$('#child1-dob-dd').empty();
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// Add Blank dd to the beginning
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$('#child1-dob-dd').append('<option value="">dd</option>');
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var Monthdays = daysInMonth(mm,yyyy);
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for(i=1; i<Monthdays+1; i++)
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{
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var strDays = (i<10?"0"+ i.toString(): i.toString());
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$('#child1-dob-dd').append('<option value="'+strDays+'">'+strDays+'</option>');
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}
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});
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// Month Event for CHILD2-DOB to reset Days to correct count for month selected.
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$("#child2-dob-mm").change(function()
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{
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var mm = $('#child2-dob-mm').val();
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var yyyy = $('#child2-dob-yyyy').val();
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// Clear Combo box before load
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$('#child2-dob-dd').empty();
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// Add Blank dd to the beginning
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$('#child2-dob-dd').append('<option value="">dd</option>');
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var Monthdays = daysInMonth(mm,yyyy);
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for(i=1; i<Monthdays+1; i++)
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{
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var strDays = (i<10?"0"+ i.toString(): i.toString());
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$('#child2-dob-dd').append('<option value="'+strDays+'">'+strDays+'</option>');
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}
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});
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// Month Event for CHILD3-DOB to reset Days to correct count for month selected.
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$("#child3-dob-mm").change
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(
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function()
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{
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var mm = $('#child3-dob-mm').val();
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var yyyy = $('#child3-dob-yyyy').val();
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// Clear Combo box before load
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$('#child3-dob-dd').empty();
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// Add Blank dd to the beginning
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$('#child3-dob-dd').append('<option value="">dd</option>');
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var Monthdays = daysInMonth(mm,yyyy);
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for(i=1; i<Monthdays+1; i++)
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{
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var strDays = (i<10?"0"+ i.toString(): i.toString());
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$('#child3-dob-dd').append('<option value="'+strDays+'">'+strDays+'</option>');
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}
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}
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);
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// Month Event for CHILD4-DOB to reset Days to correct count for month selected.
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$("#child4-dob-mm").change
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(
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function()
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{
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var mm = $('#child4-dob-mm').val();
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var yyyy = $('#child4-dob-yyyy').val();
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// Clear Combo box before load
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$('#child4-dob-dd').empty();
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// Add Blank dd to the beginning
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$('#child4-dob-dd').append('<option value="">dd</option>');
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var Monthdays = daysInMonth(mm,yyyy);
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for(i=1; i<Monthdays+1; i++)
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{
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var strDays = (i<10?"0"+ i.toString(): i.toString());
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$('#child4-dob-dd').append('<option value="'+strDays+'">'+strDays+'</option>');
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}
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}
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);
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});
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</script>
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<script>
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function goBack(pages)
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{
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window.history.go(pages);
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}
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</script>
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</head>
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<body>
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<div id="content">
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<div id="content-inside">
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<div id="header"></div>
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<div id="user-info">
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<div class="em-10">
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<label id="giftcode-label" for="giftcode">Gift Code</label>
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<input type="text" id="giftcode" name="giftcode" size="10" maxlength="10" placeholder="Gift Code" autofocus="autofocus" />
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</div>
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<div class="em-4">
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<label id="firstname-label" for="firstname">First Name</label>
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<input type="text" id="firstname" name="firstname" size="25" maxlength="40" placeholder="Please enter your first name" required="required" />
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</div>
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<div class="em-2">
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<label id="middlename-label" for="middlename">MI</label>
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<input type="text" id="middlename" name="middlename" size="2" maxlength="2" placeholder="M.I." />
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</div>
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<div class="em-4">
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<label id="lastname-label" for="lastname">Last Name</label>
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<input type="text" id="lastname" name="lastname" size="25" maxlength="40" placeholder="Please enter your last name" required="required" />
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</div>
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<div class="em-10">
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<label id="address-label" for="address">Address</label>
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<input type="text" id="address" name="address" size="10" maxlength="40" placeholder="Please enter your Address" />
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</div>
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<div class="em-4">
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<label id="city-label" for="city">City</label>
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<input type="text" id="city" name="city" size="25" maxlength="25" placeholder="Please enter your city" required="required" />
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</div>
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<div class="em-2">
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<label id="state-label" for="state">State</label>
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<div class="select-style">
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<select id="state" name="state">
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<option value=""></option>
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</select>
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</div>
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</div>
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<div class="em-4">
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<label id="zip-label" for="zip">Zip</label>
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<input type="text" id="zip" name="zip" size="13" maxlength="5" placeholder="xxxxx" required="required"pattern="\d{5}" />
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</div>
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<div class="em-4">
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<label id="phone-label" for="phone">Phone</label>
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<input type="tel" id="phone" name="phone" size="38" maxlength="12" placeholder="xxx-xxx-xxxx" pattern="\d{3}-\d{3}-\d{4}" />
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</div>
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<div class="em-6">
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<label id="email-label" for="email">EMail</label>
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<input type="text" id="email" name="email" size="10" maxlength="255" placeholder="Please enter your Address" />
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</div>
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<div class="em-4">
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<label id="dob-label">Date of Birth</label>
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<div class="select-style">
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<select id="dob-yyyy" name="dob-yyyy">
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<option value="" selected="selected">yyyy</option>
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</select>
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</div>
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<div class="select-style">
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<select id="dob-mm" name="dob-mm">
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<option value="" selected="selected">mm</option>
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</select>
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</div>
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<div class="select-style">
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<select id="dob-dd" name="dob-dd">
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<option value="" selected="selected">dd</option>
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</select>
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</div>
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</div>
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<div class="em-6">
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<label id="gender-label">Gender</label>
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<label id="gender-male-label" class="label">Male</label>
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<input type="radio" id="gender_male" name="gender" value="male" />
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<label id="gender-female-label" class="label">Female</label>
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<input type="radio" id="gender_female" name="gender" value="female" />
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</div>
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<div class="em-10">
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<label id="kids-info">My Kid`s Info</label>
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</div>
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<div class="em-5">
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<div class="seperator-odd">
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<label id="child1-dob-label">Child1</label>
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<div class="select-style">
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<select id="child1-dob-yyyy" name="child1-dob-yyyy">
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<option value="" selected="selected">yyyy</option>
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</select>
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</div>
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<div class="select-style">
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<select id="child1-dob-mm" name="child1-dob-mm">
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<option value="" selected="selected">mm</option>
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</select>
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</div>
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<div class="select-style">
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<select id="child1-dob-dd" name="child1-dob-dd">
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<option value="" selected="selected">dd</option>
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</select>
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</div>
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<label id="child1-gender-male-label">Male</label>
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<input type="radio" id="child1-gender-male" name="child1-gender" value="male" />
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<label id="child1-gender-female-label">Female</label>
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<input type="radio" id="child1-gender-female" name="child1-gender" value="female" />
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</div>
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</div>
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<div class="em-5">
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<div class="seperator-even">
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<label id="child2-dob-label">Child2</label>
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<div class="select-style">
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<select id="child2-dob-yyyy" name="child2-dob-yyyy">
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<option value="" selected="selected">yyyy</option>
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</select>
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</div>
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<div class="select-style">
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<select id="child2-dob-mm" name="child2-dob-mm">
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<option value="" selected="selected">mm</option>
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</select>
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</div>
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<div class="select-style">
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<select id="child2-dob-dd" name="child2-dob-dd">
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<option value="" selected="selected">dd</option>
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</select>
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</div>
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<label id="child2-gender-male-label">Male</label>
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<input type="radio" id="child2-gender-male" name="child2-gender" value="male" />
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<label id="child2-gender-female-label">Female</label>
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<input type="radio" id="child2-gender-female" name="child2-gender" value="female" />
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</div>
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</div>
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<div class="em-5">
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<div class="seperator-odd">
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<label id="child3-dob-label">Child3</label>
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<div class="select-style">
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<select id="child3-dob-yyyy" name="child2-dob-yyyy">
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<option value="" selected="selected">yyyy</option>
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</select>
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</div>
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<div class="select-style">
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<select id="child3-dob-mm" name="child2-dob-mmmm">
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<option value="" selected="selected">mm</option>
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</select>
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</div>
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<div class="select-style">
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<select id="child3-dob-dd" name="child2-dob-dd">
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<option value="" selected="selected">dd</option>
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</select>
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</div>
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<label id="child3-gender-male-label">Male</label>
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<input type="radio" id="child3-gender-male" name="child3-gender" value="male" />
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<label id="child3-gender-female-label">Female</label>
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<input type="radio" id="child3-gender-female" name="child3-gender" value="female" />
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</div>
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</div>
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<div class="em-5">
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<div class="seperator-even">
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<label id="child4-dob-label">Child4</label>
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<div class="select-style">
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<select id="child4-dob-yyyy" name="child2-dob-yyyy">
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<option value="" selected="selected">yyyy</option>
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</select>
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</div>
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<div class="select-style">
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<select id="child4-dob-mm" name="child2-dob-mmmm">
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<option value="" selected="selected">mm</option>
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</select>
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</div>
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<div class="select-style">
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<select id="child4-dob-dd" name="child2-dob-dd">
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<option value="" selected="selected">dd</option>
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</select>
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</div>
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<label id="child4-gender-male-label">Male</label>
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<input type="radio" id="child4-gender-male" name="child4-gender" value="male" />
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<label id="child4-gender-female-label">Female</label>
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<input type="radio" id="child4-gender-female" name="child4-gender" value="female" />
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</div>
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</div>
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<div class="em-10">
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<div class="privacy">
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Your privacy is important to us. The information gathered here will only be used
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by St.Vincent Health and will not be used or sold in any way to a third party.
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</div>
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</div>
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<div class="em-10">
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<div class="subscription-box">
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<div class="subscription-text">
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<strong>YES</strong>, I'd like to receive a subscription to the following electronic newsletter(s), delivered
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via email: <strong>Be sure to include your email address above.</strong>
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<p> </p>
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</div>
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<div class="subscription-area">
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<input type="checkbox" id="pregnancy" class="subscription-checkbox" name="pregnancy" value="pregnancy" />
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<label id="pregnancy-label" class="subscription-label" for="pregnancy">Pregnancy</label>
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<input type="checkbox" id="womens-health" class="subscription-checkbox" name="womens-health" value="womens-health" />
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<label id="womens-health-label" class="subscription-label">Women`s Health</label>
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<input type="checkbox" id="sports-performance" class="subscription-checkbox" name="sports-performance" value="sports-performance" />
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<label id="sports-performance-label" class="subscription-label">Sports Performance</label>
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<input type="checkbox" id="kids-health" class="subscription-checkbox" name="kids-health" value="kids-health" />
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<label id="kids-health-label" class="subscription-label">Kid`s Health</label>
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</div>
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</div>
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</div>
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<div class="em-10">
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<div class="free-info-text">
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Check the boxes below if you would like to receive additional free information.
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</div>
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</div>
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<div class="free-info-area">
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<input type="checkbox" id="low-fat-eating-guide" class="free-info-checkbox" name="low-fat-eating-guide" value="low-fat-eating-guide" />
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<label id="low-fat-eating-guide-label" class="free-info-label" for="low-fat-eating-guide">Low-Fat Eating Guide</label>
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<input type="checkbox" id="healthy-heart-kit" class="free-info-checkbox" name="healthy-heart-kit" value="healthy-heart-kit" />
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<label id="healthy-heart-kit-label" class="free-info-label" for="healthy-heart-kit">Healthy Heart Kit</label>
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<input type="checkbox" id="pregnancy-planning-kit" class="free-info-checkbox" name="pregnancy-planning-kit" value="pregnancy-planning-kit" />
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<label id="pregnancy-planning-kit-label" class="free-info-label" for="pregnancy-planning-kit">Pregnancy Planning Kit</label>
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<input type="checkbox" id="healthy-womens-kit" class="free-info-checkbox" name="healthy-womens-kit" value="healthy-womens-kit" />
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<label id="healthy-womens-kit-label" class="free-info-label" for="healthy-womens-kit">Healthy Women`s Kit</label>
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<input type="checkbox" id="early-parenting-kit" class="free-info-checkbox" name="early-parenting-kit" value="early-parenting-kit" />
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<label id="early-parenting-kit-label" class="free-info-label" for="early-parenting-kit">Early Parenting Kit</label>
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<input type="checkbox" id="hospital" class="free-info-checkbox" name="hospital" value="hospital" />
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<label id="hospital-label" class="free-info-label" for="hospital">Children`s Hospital</label>
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<input type="checkbox" id="surgical-weight-loss" class="free-info-checkbox" name="surgical-weight-loss" value="surgical-weight-loss" />
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<label id="surgical-weight-loss-label" class="free-info-label">Surgical Weight Loss</label>
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<input type="checkbox" id="non-surgical-weight-loss" class="free-info-checkbox" name="non-surgical-weight-loss" value="non-surgical-weight-loss" />
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<label id="non-surgical-weight-loss-label" class="free-info-label">Non-Surgical Weight Loss</label>
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<input type="checkbox" id="diabetes-education" class="free-info-checkbox" name="diabetes-education" value="diabetes-education" />
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<label id="diabetes-education-label" class="free-info-label">Diabetes Education</label>
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<input type="checkbox" id="shoulder-pain" class="free-info-checkbox" name="shoulder-pain" value="shoulder-pain" />
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<label id="shoulder-pain-label" class="free-info-label">Shoulder Pain</label>
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<input type="checkbox" id="sports-injuries" class="free-info-checkbox" name="sports-injuries" value="sports-injuries" />
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<label id="sports-injuries-label" class="free-info-label" for="sports-injuries">Sports Injuries</label>
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<input type="checkbox" id="improving-sports-performance" class="free-info-checkbox" name="improving-sports-performance" value="improving-sports-performance" />
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<label id="improving-sports-performance-label" class="free-info-label" for="improving-sports-performance">Improving your Sports Performance</label>
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<input type="checkbox" id="breast-health" class="free-info-checkbox" name="breast-health" value="breast-health" />
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<label id="breast-health-label" class="free-info-label" for="breast-health">Breast Health</label>
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<input type="checkbox" id="cancer-screening-tool" class="free-info-checkbox" name="cancer-screening-tool" value="cancer-screening-tool" />
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<label id="cancer-screening-tool-label" class="free-info-label" for="cancer-screening-tool">Cancer Screening Tool</label>
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<input type="checkbox" id="stroke-risk" class="free-info-checkbox" name="stroke-risk" value="stroke-risk" />
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<label id="stroke-risk-label" class="free-info-label" for="stroke-risk">Are You at Risk for Stroke</label>
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<input type="checkbox" id="hearing-loss" class="free-info-checkbox" name="hearing-loss" value="hearing-loss" />
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<label id="hearing-loss-label" class="free-info-label" for="hearing-loss">Hearing Loss</label>
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<input type="checkbox" id="immediate-care" class="free-info-checkbox" name="immediate-care" value="immediate-care" />
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<label id="immediate-care-label" class="free-info-label" for="immediate-care">Immediate Care</label>
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<input type="checkbox" id="stress-management" class="free-info-checkbox" name="stress-management" value="stress-management" />
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<label id="stress-management-label" class="free-info-label" for="stress-management">Stress Management</label>
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<input type="checkbox" id="adhd" class="free-info-checkbox" name="adhd" value="adhd" />
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<label id="adhd-label" class="free-info-label" for="adhd">ADHD</label>
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<input type="checkbox" id="joint-pain" class="free-info-checkbox" name="joint-pain" value="joint-pain" />
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<label id="joint-pain-label" class="free-info-label" for="joint-pain">Joint Pain</label>
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<input type="checkbox" id="varicose-veins" class="free-info-checkbox" name="varicose-veins" value="varicose-veins" />
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<label id="varicose-veins-label" class="free-info-label" for="varicose-veins">Varicose Veins</label>
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<input type="checkbox" id="senior-health-services" class="free-info-checkbox" name="senior-health-services" value="senior-health-services" />
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<label id="senior-health-services-label" class="free-info-label" for="senior-health-services">Senior Health Services</label>
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</div>
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<div class="em-10">
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</div>
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<div class="em-10">
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<div class="button-save">
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<div class="left-button"></div>
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<div class="center-button">
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<span class="button-text" onClick="goBack(-1)">Save Transaction</span>
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</div>
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<div class="right-button"></div>
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</div>
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<div class="button-clear">
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<div class="left-button"></div>
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<div class="center-button">
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<span class="button-text" onClick="goBack(-1)">Clear Transaction</span>
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</div>
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<div class="right-button"></div>
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</div>
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</div>
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</div> <!-- user-info -->
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</div> <!-- content-inside -->
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</div> <!-- content -->
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<noscript>
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<p>Javascript has to be enabled to use this page.</p>
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</noscript>
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</body>
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</html>
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