{"id":3823,"date":"2021-05-19T17:23:52","date_gmt":"2021-05-19T17:23:52","guid":{"rendered":"https:\/\/coi.iris.rt5.ca\/?page_id=3823"},"modified":"2021-05-19T17:23:52","modified_gmt":"2021-05-19T17:23:52","slug":"follow-up-form-laser","status":"publish","type":"page","link":"https:\/\/coi.iris.rt5.ca\/en\/follow-up-form-laser\/","title":{"rendered":"Follow up form laser"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_19' ><form method='post' enctype='multipart\/form-data'  id='gform_19'  action='\/en\/wp-json\/wp\/v2\/pages\/3823' data-formid='19' >\n                        <div class='gform-body gform_body'><ul id='gform_fields_19' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_19_113\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_113\"><h1 style=\"text-align: center; padding-bottom: 1rem;\">Post-operative evaluation form - Laser surgery<\/h1><\/li><li id=\"field_19_31\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_31\"><h2 class=\"gsection_title\">Identification<\/h2><\/li><li id=\"field_19_34\"  class=\"gfield gfield--type-text gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_34\"><label class='gfield_label gform-field-label' for='input_19_34' >Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_19_34' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_35\"  class=\"gfield gfield--type-text gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_35\"><label class='gfield_label gform-field-label' for='input_19_35' >First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_19_35' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_9\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_9\"><label class='gfield_label gform-field-label' for='input_19_9' >Post-Op Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_9' id='input_19_9' type='text' value='' class='datepicker gform-datepicker ymd_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='yyyy-mm-dd' aria-describedby=\"input_19_9_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_19_9_date_format' class='screen-reader-text'>YYYY dash MM dash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_19_9' class='gform_hidden' value='https:\/\/coi.iris.rt5.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_19_120\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_120\"><label class='gfield_label gform-field-label' for='input_19_120' >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_120' id='input_19_120' type='text' value='' class='datepicker gform-datepicker ymd_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='yyyy-mm-dd' aria-describedby=\"input_19_120_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_19_120_date_format' class='screen-reader-text'>YYYY dash MM dash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_19_120' class='gform_hidden' value='https:\/\/coi.iris.rt5.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_19_8\"  class=\"gfield gfield--type-number gf_middle_third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_8\"><label class='gfield_label gform-field-label' for='input_19_8' >Age<\/label><div class='ginput_container ginput_container_number'><input name='input_8' id='input_19_8' type='text'    value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_19_11\"  class=\"gfield gfield--type-number gf_right_third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_11\"><label class='gfield_label gform-field-label' for='input_19_11' >#chart\/at our clinic<\/label><div class='ginput_container ginput_container_number'><input name='input_11' id='input_19_11' type='text'    value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_19_27\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_27\"><h2 class=\"gsection_title\">Symptoms<\/h2><\/li><li id=\"field_19_13\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_4col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_13\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Distance vision<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_13'><li class='gchoice gchoice_19_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='excellent'  id='choice_19_13_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_13_1' id='label_19_13_1' class='gform-field-label gform-field-label--type-inline'>excellent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='good'  id='choice_19_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_13_2' id='label_19_13_2' class='gform-field-label gform-field-label--type-inline'>good<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='difficult'  id='choice_19_13_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_13_3' id='label_19_13_3' class='gform-field-label gform-field-label--type-inline'>difficult<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='unsatisfactory'  id='choice_19_13_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_13_4' id='label_19_13_4' class='gform-field-label gform-field-label--type-inline'>unsatisfactory<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_15\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_4col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_15\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Near vision<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_15'><li class='gchoice gchoice_19_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='excellent'  id='choice_19_15_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_15_1' id='label_19_15_1' class='gform-field-label gform-field-label--type-inline'>excellent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_15_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.2' type='checkbox'  value='good'  id='choice_19_15_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_15_2' id='label_19_15_2' class='gform-field-label gform-field-label--type-inline'>good<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_15_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.3' type='checkbox'  value='difficult'  id='choice_19_15_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_15_3' id='label_19_15_3' class='gform-field-label gform-field-label--type-inline'>difficult<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_15_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.4' type='checkbox'  value='unsatisfactory'  id='choice_19_15_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_15_4' id='label_19_15_4' class='gform-field-label gform-field-label--type-inline'>unsatisfactory<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_16\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_4col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_16\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Dry Eyes<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_16'><li class='gchoice gchoice_19_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='excellent'  id='choice_19_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_16_1' id='label_19_16_1' class='gform-field-label gform-field-label--type-inline'>excellent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='good'  id='choice_19_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_16_2' id='label_19_16_2' class='gform-field-label gform-field-label--type-inline'>good<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='difficult'  id='choice_19_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_16_3' id='label_19_16_3' class='gform-field-label gform-field-label--type-inline'>difficult<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='unsatisfactory'  id='choice_19_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_16_4' id='label_19_16_4' class='gform-field-label gform-field-label--type-inline'>unsatisfactory<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_17\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_4col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_17\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Glare<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_17'><li class='gchoice gchoice_19_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='excellent'  id='choice_19_17_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_17_1' id='label_19_17_1' class='gform-field-label gform-field-label--type-inline'>excellent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='good'  id='choice_19_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_17_2' id='label_19_17_2' class='gform-field-label gform-field-label--type-inline'>good<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_17_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.3' type='checkbox'  value='difficult'  id='choice_19_17_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_17_3' id='label_19_17_3' class='gform-field-label gform-field-label--type-inline'>difficult<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_17_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.4' type='checkbox'  value='unsatisfactory'  id='choice_19_17_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_17_4' id='label_19_17_4' class='gform-field-label gform-field-label--type-inline'>unsatisfactory<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_18\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_4col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_18\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Halos<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_18'><li class='gchoice gchoice_19_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='excellent'  id='choice_19_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_18_1' id='label_19_18_1' class='gform-field-label gform-field-label--type-inline'>excellent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='good'  id='choice_19_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_18_2' id='label_19_18_2' class='gform-field-label gform-field-label--type-inline'>good<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='difficult'  id='choice_19_18_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_18_3' id='label_19_18_3' class='gform-field-label gform-field-label--type-inline'>difficult<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_18_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.4' type='checkbox'  value='unsatisfactory'  id='choice_19_18_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_18_4' id='label_19_18_4' class='gform-field-label gform-field-label--type-inline'>unsatisfactory<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_19\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_4col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_19\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Pain<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_19'><li class='gchoice gchoice_19_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='excellent'  id='choice_19_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_19_1' id='label_19_19_1' class='gform-field-label gform-field-label--type-inline'>excellent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='good'  id='choice_19_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_19_2' id='label_19_19_2' class='gform-field-label gform-field-label--type-inline'>good<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_19_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='difficult'  id='choice_19_19_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_19_3' id='label_19_19_3' class='gform-field-label gform-field-label--type-inline'>difficult<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_19_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.4' type='checkbox'  value='unsatisfactory'  id='choice_19_19_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_19_4' id='label_19_19_4' class='gform-field-label gform-field-label--type-inline'>unsatisfactory<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_21\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_21\"><label class='gfield_label gform-field-label' for='input_19_21' >Additional comments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_19_21' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_19_28\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_28\"><h2 class=\"gsection_title\">Surgery<\/h2><\/li><li id=\"field_19_122\"  class=\"gfield gfield--type-radio gfield--type-choice gf_left_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_122\"><label class='gfield_label gform-field-label'  >Context<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_19_122'>\n\t\t\t<li class='gchoice gchoice_19_122_0'>\n\t\t\t\t<input name='input_122' type='radio' value='1st surgery'  id='choice_19_122_0'    \/>\n\t\t\t\t<label for='choice_19_122_0' id='label_19_122_0' class='gform-field-label gform-field-label--type-inline'>1st surgery<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_19_122_1'>\n\t\t\t\t<input name='input_122' type='radio' value='Touch-up\/2d surgery'  id='choice_19_122_1'    \/>\n\t\t\t\t<label for='choice_19_122_1' id='label_19_122_1' class='gform-field-label gform-field-label--type-inline'>Touch-up\/2d surgery<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_123\"  class=\"gfield gfield--type-html gf_right_half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_123\"><\/li><li id=\"field_19_116\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_6col gf_left_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_116\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Delay since surgery - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_116'><li class='gchoice gchoice_19_116_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_116.1' type='checkbox'  value='1 week'  id='choice_19_116_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_116_1' id='label_19_116_1' class='gform-field-label gform-field-label--type-inline'>1 week<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_116_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_116.2' type='checkbox'  value='1 month'  id='choice_19_116_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_116_2' id='label_19_116_2' class='gform-field-label gform-field-label--type-inline'>1 month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_116_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_116.3' type='checkbox'  value='3 month'  id='choice_19_116_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_116_3' id='label_19_116_3' class='gform-field-label gform-field-label--type-inline'>3 month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_116_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_116.4' type='checkbox'  value='6 month'  id='choice_19_116_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_116_4' id='label_19_116_4' class='gform-field-label gform-field-label--type-inline'>6 month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_116_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_116.5' type='checkbox'  value='1 year'  id='choice_19_116_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_116_5' id='label_19_116_5' class='gform-field-label gform-field-label--type-inline'>1 year<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_116_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_116.6' type='checkbox'  value='other'  id='choice_19_116_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_116_6' id='label_19_116_6' class='gform-field-label gform-field-label--type-inline'>other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_117\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_6col gf_right_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_117\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Delay since surgery - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_117'><li class='gchoice gchoice_19_117_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_117.1' type='checkbox'  value='1 week'  id='choice_19_117_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_117_1' id='label_19_117_1' class='gform-field-label gform-field-label--type-inline'>1 week<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_117_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_117.2' type='checkbox'  value='1 month'  id='choice_19_117_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_117_2' id='label_19_117_2' class='gform-field-label gform-field-label--type-inline'>1 month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_117_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_117.3' type='checkbox'  value='3 month'  id='choice_19_117_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_117_3' id='label_19_117_3' class='gform-field-label gform-field-label--type-inline'>3 month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_117_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_117.4' type='checkbox'  value='6 month'  id='choice_19_117_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_117_4' id='label_19_117_4' class='gform-field-label gform-field-label--type-inline'>6 month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_117_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_117.5' type='checkbox'  value='1 year'  id='choice_19_117_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_117_5' id='label_19_117_5' class='gform-field-label gform-field-label--type-inline'>1 year<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_117_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_117.6' type='checkbox'  value='other'  id='choice_19_117_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_117_6' id='label_19_117_6' class='gform-field-label gform-field-label--type-inline'>other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_23\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_2col gf_left_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_23\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Type of surgery - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_23'><li class='gchoice gchoice_19_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Lasik'  id='choice_19_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_23_1' id='label_19_23_1' class='gform-field-label gform-field-label--type-inline'>Lasik<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='Surface ablation (PRK)'  id='choice_19_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_23_2' id='label_19_23_2' class='gform-field-label gform-field-label--type-inline'>Surface ablation (PRK)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_24\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_2col gf_right_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_24\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Type of Surgery - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_24'><li class='gchoice gchoice_19_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Lasik'  id='choice_19_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_24_1' id='label_19_24_1' class='gform-field-label gform-field-label--type-inline'>Lasik<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Surface ablation (PRK)'  id='choice_19_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_24_2' id='label_19_24_2' class='gform-field-label gform-field-label--type-inline'>Surface ablation (PRK)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_118\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_2col gf_left_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_118\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Targeted correction - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_118'><li class='gchoice gchoice_19_118_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.1' type='checkbox'  value='DV'  id='choice_19_118_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_118_1' id='label_19_118_1' class='gform-field-label gform-field-label--type-inline'>DV<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_118_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.2' type='checkbox'  value='NV'  id='choice_19_118_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_118_2' id='label_19_118_2' class='gform-field-label gform-field-label--type-inline'>NV<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_119\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_2col gf_right_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_119\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Targeted correction - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_119'><li class='gchoice gchoice_19_119_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_119.1' type='checkbox'  value='DV'  id='choice_19_119_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_119_1' id='label_19_119_1' class='gform-field-label gform-field-label--type-inline'>DV<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_119_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_119.2' type='checkbox'  value='NV'  id='choice_19_119_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_119_2' id='label_19_119_2' class='gform-field-label gform-field-label--type-inline'>NV<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_124\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_124\"><h2 class=\"gsection_title\">UCVA DV<\/h2><\/li><li id=\"field_19_125\"  class=\"gfield gfield--type-html gf_first_quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_125\"><div><strong>UCVA DV - OU<\/strong><\/div><\/li><li id=\"field_19_126\"  class=\"gfield gfield--type-text gf_second_quarter six_slash field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_19_126\"><label class='gfield_label gform-field-label' for='input_19_126' >6\/<\/label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_19_126' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_127\"  class=\"gfield gfield--type-html gf_third_quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_127\"><\/li><li id=\"field_19_128\"  class=\"gfield gfield--type-html gf_fourth_quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_128\"><\/li><li id=\"field_19_84\"  class=\"gfield gfield--type-html gf_left_half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_84\"><div><strong>UCVA DV - OD<\/strong><\/div><\/li><li id=\"field_19_87\"  class=\"gfield gfield--type-html gf_right_half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_87\"><div><strong>UCVA DV - OS<\/strong><\/div><\/li><li id=\"field_19_85\"  class=\"gfield gfield--type-text gf_left_half six_slash field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_19_85\"><label class='gfield_label gform-field-label' for='input_19_85' >6\/<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_19_85' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_88\"  class=\"gfield gfield--type-text gf_right_half six_slash field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_19_88\"><label class='gfield_label gform-field-label' for='input_19_88' >6\/<\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_19_88' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_129\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_129\"><h2 class=\"gsection_title\">UCVA NV - OU<\/h2><\/li><li id=\"field_19_130\"  class=\"gfield gfield--type-html gf_first_quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_130\"><div><strong>UCVA NV  M at cm - OU<\/strong><\/div><\/li><li id=\"field_19_131\"  class=\"gfield gfield--type-text gf_second_quarter six_slash_m field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_19_131\"><label class='gfield_label gform-field-label' for='input_19_131' >M<\/label><div class='ginput_container ginput_container_text'><input name='input_131' id='input_19_131' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_132\"  class=\"gfield gfield--type-text gf_third_quarter six_slash_a_cm field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_19_132\"><label class='gfield_label gform-field-label' for='input_19_132' >At cm<\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_19_132' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_133\"  class=\"gfield gfield--type-html gf_fourth_quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_133\"><\/li><li id=\"field_19_90\"  class=\"gfield gfield--type-html gf_left_half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_90\"><div><strong>UCVA NV  M at cm - OD<\/strong><\/div><\/li><li id=\"field_19_91\"  class=\"gfield gfield--type-html gf_right_half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_91\"><div><strong>UCVA NV  M at cm - OS<\/strong><\/div><\/li><li id=\"field_19_92\"  class=\"gfield gfield--type-text gf_first_quarter six_slash_m field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_19_92\"><label class='gfield_label gform-field-label' for='input_19_92' >M<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_19_92' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_93\"  class=\"gfield gfield--type-text gf_first_quarter six_slash_a_cm field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_19_93\"><label class='gfield_label gform-field-label' for='input_19_93' >at cm<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_19_93' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_94\"  class=\"gfield gfield--type-text gf_third_quarter six_slash_m field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_19_94\"><label class='gfield_label gform-field-label' for='input_19_94' >M<\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_19_94' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_95\"  class=\"gfield gfield--type-text gf_fourth_quarter six_slash_a_cm field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_19_95\"><label class='gfield_label gform-field-label' for='input_19_95' >at cm<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_19_95' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_134\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_134\"><h2 class=\"gsection_title\">Refraction<\/h2><\/li><li id=\"field_19_96\"  class=\"gfield gfield--type-html gf_left_half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_96\"><div><strong>Subjective Refraction - OD<\/strong><\/div><\/li><li id=\"field_19_99\"  class=\"gfield gfield--type-html gf_left_half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_99\"><div><strong>Subjective Refraction - OS<\/strong><\/div><\/li><li id=\"field_19_97\"  class=\"gfield gfield--type-text gf_first_quarter input_5t field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_19_97\"><label class='gfield_label gform-field-label' for='input_19_97' >Subjective Refraction - OD<\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_19_97' type='text' value='' class='medium'    placeholder='0.00'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_98\"  class=\"gfield gfield--type-text gf_second_quarter six_slash field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_19_98\"><label class='gfield_label gform-field-label' for='input_19_98' >Subjective Refraction - od 6\/<\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_19_98' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_100\"  class=\"gfield gfield--type-text gf_third_quarter input_5t field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_19_100\"><label class='gfield_label gform-field-label' for='input_19_100' >Subjective Refraction - OS<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_19_100' type='text' value='' class='medium'    placeholder='0.00'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_101\"  class=\"gfield gfield--type-text gf_fourth_quarter six_slash field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_19_101\"><label class='gfield_label gform-field-label' for='input_19_101' >Subjective Refraction - os 6\/<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_19_101' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_102\"  class=\"gfield gfield--type-html gf_left_half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_102\"><div><strong>Electronic Refraction - OD<\/strong><\/div><\/li><li id=\"field_19_103\"  class=\"gfield gfield--type-html gf_left_half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_103\"><div><strong>Electronic Refraction - OS<\/strong><\/div><\/li><li id=\"field_19_104\"  class=\"gfield gfield--type-text gf_first_quarter input_5t field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_19_104\"><label class='gfield_label gform-field-label' for='input_19_104' >Subjective Refraction - OD<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_19_104' type='text' value='' class='medium'    placeholder='0.00'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_105\"  class=\"gfield gfield--type-text gf_second_quarter six_slash field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_19_105\"><label class='gfield_label gform-field-label' for='input_19_105' >Subjective Refraction - od 6\/<\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_19_105' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_106\"  class=\"gfield gfield--type-text gf_third_quarter input_5t field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_19_106\"><label class='gfield_label gform-field-label' for='input_19_106' >Subjective Refraction - OS<\/label><div class='ginput_container ginput_container_text'><input name='input_106' id='input_19_106' type='text' value='' class='medium'    placeholder='0.00'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_107\"  class=\"gfield gfield--type-text gf_fourth_quarter six_slash field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_19_107\"><label class='gfield_label gform-field-label' for='input_19_107' >Subjective Refraction - os 6\/<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_19_107' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_108\"  class=\"gfield gfield--type-time gf_left_third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_108\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Intraocular pressure<\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_19_108'>\n                            <input type='text' maxlength='2' name='input_108[]' id='input_19_108_1' value=''    placeholder='HH' aria-required='false'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_19_108_1'>Hours<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='text' maxlength='2' name='input_108[]' id='input_19_108_2' value=''    placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_19_108_2'>Minutes<\/label>\n                        <\/div>\n                        \n                    <\/div><\/div><\/li><li id=\"field_19_111\"  class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_2col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_111\"><label class='gfield_label gform-field-label'  >Method<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_19_111'>\n\t\t\t<li class='gchoice gchoice_19_111_0'>\n\t\t\t\t<input name='input_111' type='radio' value='NCT (Air jet)'  id='choice_19_111_0'    \/>\n\t\t\t\t<label for='choice_19_111_0' id='label_19_111_0' class='gform-field-label gform-field-label--type-inline'>NCT (Air jet)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_19_111_1'>\n\t\t\t\t<input name='input_111' type='radio' value='Goldmann (aplanation)'  id='choice_19_111_1'    \/>\n\t\t\t\t<label for='choice_19_111_1' id='label_19_111_1' class='gform-field-label gform-field-label--type-inline'>Goldmann (aplanation)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_109\"  class=\"gfield gfield--type-text gf_first_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_109\"><label class='gfield_label gform-field-label' for='input_19_109' >IOP - OD<\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_19_109' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_110\"  class=\"gfield gfield--type-text gf_second_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_110\"><label class='gfield_label gform-field-label' for='input_19_110' >IOP - OS<\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_19_110' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_1\"  class=\"gfield gfield--type-signature gf_third_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_1\"><label class='gfield_label gform-field-label' for='input_19_1' >Left Eye<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_19_1_Container' class='gfield_signature_container ginput_container' style='height:180px; width:180px; ' ><input type='hidden' class='gform_hidden' name='input_19_1_valid' id='input_19_1_valid' \/><canvas id='input_19_1' width='180' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_19_3\"  class=\"gfield gfield--type-signature gf_fourth_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_3\"><label class='gfield_label gform-field-label' for='input_19_3' >Right Eye<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_19_3_Container' class='gfield_signature_container ginput_container' style='height:180px; width:180px; ' ><input type='hidden' class='gform_hidden' name='input_19_3_valid' id='input_19_3_valid' \/><canvas id='input_19_3' width='180' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_19_135\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_135\"><h2 class=\"gsection_title\">Grades<\/h2><\/li><li id=\"field_19_136\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_136\"><div style=\"text-align: center;\"><strong>1\/2: trace&nbsp;&nbsp;&nbsp;1: minor&nbsp;&nbsp;&nbsp2: moderate&nbsp;&nbsp;&nbsp;3: moderately significant&nbsp;&nbsp;&nbsp;4: severe<\/strong><\/div><\/li><li id=\"field_19_43\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter first field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_43\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Hyperemia - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_43'><li class='gchoice gchoice_19_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='none'  id='choice_19_43_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_43_1' id='label_19_43_1' class='gform-field-label gform-field-label--type-inline'>none<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_43_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.2' type='checkbox'  value='present'  id='choice_19_43_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_43_2' id='label_19_43_2' class='gform-field-label gform-field-label--type-inline'>present<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_44\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_44\"><label class='gfield_label gform-field-label' for='input_19_44' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_19_44' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_45\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_45\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Hyperemia - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_45'><li class='gchoice gchoice_19_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='none'  id='choice_19_45_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_45_1' id='label_19_45_1' class='gform-field-label gform-field-label--type-inline'>none<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='present'  id='choice_19_45_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_45_2' id='label_19_45_2' class='gform-field-label gform-field-label--type-inline'>present<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_46\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_46\"><label class='gfield_label gform-field-label' for='input_19_46' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_19_46' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_47\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter first field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_47\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Epithelial erosion - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_47'><li class='gchoice gchoice_19_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='none'  id='choice_19_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_47_1' id='label_19_47_1' class='gform-field-label gform-field-label--type-inline'>none<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='present'  id='choice_19_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_47_2' id='label_19_47_2' class='gform-field-label gform-field-label--type-inline'>present<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_48\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_48\"><label class='gfield_label gform-field-label' for='input_19_48' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_19_48' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_49\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_49\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Epithelial erosion - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_49'><li class='gchoice gchoice_19_49_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.1' type='checkbox'  value='none'  id='choice_19_49_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_49_1' id='label_19_49_1' class='gform-field-label gform-field-label--type-inline'>none<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_49_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.2' type='checkbox'  value='present'  id='choice_19_49_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_49_2' id='label_19_49_2' class='gform-field-label gform-field-label--type-inline'>present<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_50\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_50\"><label class='gfield_label gform-field-label' for='input_19_50' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_19_50' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_51\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter first field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_51\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >SPK - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_51'><li class='gchoice gchoice_19_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='none'  id='choice_19_51_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_51_1' id='label_19_51_1' class='gform-field-label gform-field-label--type-inline'>none<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_51_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.2' type='checkbox'  value='present'  id='choice_19_51_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_51_2' id='label_19_51_2' class='gform-field-label gform-field-label--type-inline'>present<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_52\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_52\"><label class='gfield_label gform-field-label' for='input_19_52' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_19_52' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_53\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_53\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >SPK - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_53'><li class='gchoice gchoice_19_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='\u00e9tanche'  id='choice_19_53_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_53_1' id='label_19_53_1' class='gform-field-label gform-field-label--type-inline'>\u00e9tanche<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_53_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.2' type='checkbox'  value='fuite'  id='choice_19_53_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_53_2' id='label_19_53_2' class='gform-field-label gform-field-label--type-inline'>fuite<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_54\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_54\"><label class='gfield_label gform-field-label' for='input_19_54' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_19_54' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_36\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter first field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_36\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Sub-epithelial fibrosis (haze) - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_36'><li class='gchoice gchoice_19_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='none'  id='choice_19_36_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_36_1' id='label_19_36_1' class='gform-field-label gform-field-label--type-inline'>none<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_36_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.2' type='checkbox'  value='present'  id='choice_19_36_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_36_2' id='label_19_36_2' class='gform-field-label gform-field-label--type-inline'>present<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_37\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_37\"><label class='gfield_label gform-field-label' for='input_19_37' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_19_37' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_38\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_38\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Sub-epithelial fibrosis (haze) - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_38'><li class='gchoice gchoice_19_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='none'  id='choice_19_38_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_38_1' id='label_19_38_1' class='gform-field-label gform-field-label--type-inline'>none<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_38_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.2' type='checkbox'  value='present'  id='choice_19_38_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_38_2' id='label_19_38_2' class='gform-field-label gform-field-label--type-inline'>present<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_39\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_39\"><label class='gfield_label gform-field-label' for='input_19_39' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_19_39' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_55\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_left_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_55\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Flap: Striaes\/Folds - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_55'><li class='gchoice gchoice_19_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='none'  id='choice_19_55_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_55_1' id='label_19_55_1' class='gform-field-label gform-field-label--type-inline'>none<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_55_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.2' type='checkbox'  value='micro'  id='choice_19_55_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_55_2' id='label_19_55_2' class='gform-field-label gform-field-label--type-inline'>micro<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_55_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.3' type='checkbox'  value='macro'  id='choice_19_55_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_55_3' id='label_19_55_3' class='gform-field-label gform-field-label--type-inline'>macro<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_55_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.4' type='checkbox'  value='periph'  id='choice_19_55_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_55_4' id='label_19_55_4' class='gform-field-label gform-field-label--type-inline'>periph<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_55_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.5' type='checkbox'  value='central'  id='choice_19_55_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_55_5' id='label_19_55_5' class='gform-field-label gform-field-label--type-inline'>central<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_57\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_left_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_57\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Flap: Striaes\/Folds - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_57'><li class='gchoice gchoice_19_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='none'  id='choice_19_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_57_1' id='label_19_57_1' class='gform-field-label gform-field-label--type-inline'>none<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_57_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.2' type='checkbox'  value='micro'  id='choice_19_57_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_57_2' id='label_19_57_2' class='gform-field-label gform-field-label--type-inline'>micro<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_57_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.3' type='checkbox'  value='macro'  id='choice_19_57_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_57_3' id='label_19_57_3' class='gform-field-label gform-field-label--type-inline'>macro<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_57_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.4' type='checkbox'  value='periph'  id='choice_19_57_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_57_4' id='label_19_57_4' class='gform-field-label gform-field-label--type-inline'>periph<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_57_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.5' type='checkbox'  value='central'  id='choice_19_57_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_57_5' id='label_19_57_5' class='gform-field-label gform-field-label--type-inline'>central<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_60\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_left_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_60\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >FLAP: Margins - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_60'><li class='gchoice gchoice_19_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='r\u00e9gulier'  id='choice_19_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_60_1' id='label_19_60_1' class='gform-field-label gform-field-label--type-inline'>r\u00e9gulier<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_60_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.2' type='checkbox'  value='irr\u00e9gulier'  id='choice_19_60_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_60_2' id='label_19_60_2' class='gform-field-label gform-field-label--type-inline'>irr\u00e9gulier<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_62\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_right_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_62\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >FLAP: Margins - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_62'><li class='gchoice gchoice_19_62_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.1' type='checkbox'  value='regular'  id='choice_19_62_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_62_1' id='label_19_62_1' class='gform-field-label gform-field-label--type-inline'>regular<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_62_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.2' type='checkbox'  value='irregular'  id='choice_19_62_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_62_2' id='label_19_62_2' class='gform-field-label gform-field-label--type-inline'>irregular<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_65\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_left_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_65\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Interface - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_65'><li class='gchoice gchoice_19_65_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.1' type='checkbox'  value='clean'  id='choice_19_65_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_65_1' id='label_19_65_1' class='gform-field-label gform-field-label--type-inline'>clean<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_65_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.2' type='checkbox'  value='debris'  id='choice_19_65_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_65_2' id='label_19_65_2' class='gform-field-label gform-field-label--type-inline'>debris<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_65_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.3' type='checkbox'  value='opacity'  id='choice_19_65_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_65_3' id='label_19_65_3' class='gform-field-label gform-field-label--type-inline'>opacity<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_65_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.4' type='checkbox'  value='fibrosis'  id='choice_19_65_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_65_4' id='label_19_65_4' class='gform-field-label gform-field-label--type-inline'>fibrosis<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_67\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_right_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_67\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Interface - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_67'><li class='gchoice gchoice_19_67_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.1' type='checkbox'  value='clean'  id='choice_19_67_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_67_1' id='label_19_67_1' class='gform-field-label gform-field-label--type-inline'>clean<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_67_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.2' type='checkbox'  value='debris'  id='choice_19_67_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_67_2' id='label_19_67_2' class='gform-field-label gform-field-label--type-inline'>debris<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_67_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.3' type='checkbox'  value='opacity'  id='choice_19_67_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_67_3' id='label_19_67_3' class='gform-field-label gform-field-label--type-inline'>opacity<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_67_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.4' type='checkbox'  value='fibrosis'  id='choice_19_67_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_67_4' id='label_19_67_4' class='gform-field-label gform-field-label--type-inline'>fibrosis<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_137\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter first field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_137\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Diffuse Lamellar Keratitis (DLK) - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_137'><li class='gchoice gchoice_19_137_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_137.1' type='checkbox'  value='absent'  id='choice_19_137_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_137_1' id='label_19_137_1' class='gform-field-label gform-field-label--type-inline'>absent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_137_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_137.2' type='checkbox'  value='present'  id='choice_19_137_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_137_2' id='label_19_137_2' class='gform-field-label gform-field-label--type-inline'>present<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_66\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_66\"><label class='gfield_label gform-field-label' for='input_19_66' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_19_66' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_138\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_138\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Diffuse Lamellar Keratitis (DLK) - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_138'><li class='gchoice gchoice_19_138_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_138.1' type='checkbox'  value='absent'  id='choice_19_138_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_138_1' id='label_19_138_1' class='gform-field-label gform-field-label--type-inline'>absent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_138_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_138.2' type='checkbox'  value='present'  id='choice_19_138_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_138_2' id='label_19_138_2' class='gform-field-label gform-field-label--type-inline'>present<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_68\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_68\"><label class='gfield_label gform-field-label' for='input_19_68' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_19_68' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_139\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter first field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_139\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Epithelial ingrowth - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_139'><li class='gchoice gchoice_19_139_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.1' type='checkbox'  value='absent'  id='choice_19_139_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_139_1' id='label_19_139_1' class='gform-field-label gform-field-label--type-inline'>absent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_139_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.2' type='checkbox'  value='present'  id='choice_19_139_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_139_2' id='label_19_139_2' class='gform-field-label gform-field-label--type-inline'>present<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_140\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_140\"><label class='gfield_label gform-field-label' for='input_19_140' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_19_140' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_141\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_141\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Epithelial ingrowth - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_141'><li class='gchoice gchoice_19_141_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_141.1' type='checkbox'  value='absent'  id='choice_19_141_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_141_1' id='label_19_141_1' class='gform-field-label gform-field-label--type-inline'>absent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_141_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_141.2' type='checkbox'  value='present'  id='choice_19_141_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_141_2' id='label_19_141_2' class='gform-field-label gform-field-label--type-inline'>present<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_142\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_142\"><label class='gfield_label gform-field-label' for='input_19_142' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_142' id='input_19_142' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_73\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_73\"><br \/><\/li><li id=\"field_19_72\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_72\"><label class='gfield_label gform-field-label' for='input_19_72' >Recommandations<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_72' id='input_19_72' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_19_115\"  class=\"gfield gfield--type-text gf_list_2col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_115\"><label class='gfield_label gform-field-label' for='input_19_115' >Next checkup<\/label><div class='ginput_container ginput_container_text'><input name='input_115' id='input_19_115' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_19_74\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_2col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_74\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Communication<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_74'><li class='gchoice gchoice_19_74_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.1' type='checkbox'  value='I have additional inormations and I would like you to communicate with me regarding this patient'  id='choice_19_74_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_74_1' id='label_19_74_1' class='gform-field-label gform-field-label--type-inline'>I have additional inormations and I would like you to communicate with me regarding this patient<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_74_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.2' type='checkbox'  value='Urgent'  id='choice_19_74_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_74_2' id='label_19_74_2' class='gform-field-label gform-field-label--type-inline'>Urgent<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_76\"  class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_19_76\"><label class='gfield_label gform-field-label' for='input_19_76' >Optometrist<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_19_76' type='text' value='' class='medium'     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