{"id":1191,"date":"2016-12-22T14:41:02","date_gmt":"2016-12-22T19:41:02","guid":{"rendered":"http:\/\/plankdev2.com\/?page_id=1191"},"modified":"2016-12-22T14:54:09","modified_gmt":"2016-12-22T19:54:09","slug":"patient-survey","status":"publish","type":"page","link":"https:\/\/lowcountrypt.com\/patient-survey\/","title":{"rendered":"Patient Survey"},"content":{"rendered":"<div id='av_section_1'  class='avia-section av-av_section-bb9bdb22c7f9e6bf1d52c155825dc7f7 main_color avia-section-default avia-no-shadow  avia-builder-el-0  avia-builder-el-no-sibling  avia-bg-style-scroll container_wrap sidebar_right'  ><div class='container av-section-cont-open' ><main  role=\"main\" itemprop=\"mainContentOfPage\"  class='template-page content  av-content-small alpha units'><div class='post-entry post-entry-type-page post-entry-1191'><div class='entry-content-wrapper clearfix'>\n\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-av_heading-d3cffafcb319e4b17313adb259fa09a9\">\n#top .av-special-heading.av-av_heading-d3cffafcb319e4b17313adb259fa09a9{\npadding-bottom:10px;\nfont-size:46px;\n}\nbody .av-special-heading.av-av_heading-d3cffafcb319e4b17313adb259fa09a9 .av-special-heading-tag .heading-char{\nfont-size:25px;\n}\n#top #wrap_all .av-special-heading.av-av_heading-d3cffafcb319e4b17313adb259fa09a9 .av-special-heading-tag{\nfont-size:46px;\n}\n.av-special-heading.av-av_heading-d3cffafcb319e4b17313adb259fa09a9 .av-subheading{\nfont-size:15px;\n}\n\n@media only screen and (min-width: 480px) and (max-width: 767px){ \n#top #wrap_all .av-special-heading.av-av_heading-d3cffafcb319e4b17313adb259fa09a9 .av-special-heading-tag{\nfont-size:0.8em;\n}\n}\n\n@media only screen and (max-width: 479px){ \n#top #wrap_all .av-special-heading.av-av_heading-d3cffafcb319e4b17313adb259fa09a9 .av-special-heading-tag{\nfont-size:0.8em;\n}\n}\n<\/style>\n<div  class='av-special-heading av-av_heading-d3cffafcb319e4b17313adb259fa09a9 av-special-heading-h1 blockquote modern-quote modern-centered  avia-builder-el-1  el_before_av_hr  avia-builder-el-first  av-inherit-size'><h1 class='av-special-heading-tag'  itemprop=\"headline\"  >Patient Survey<\/h1><div class=\"special-heading-border\"><div class=\"special-heading-inner-border\"><\/div><\/div><\/div>\n\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-av_hr-88feb0b61b1485a8eff0710aa16ca233\">\n#top .hr.av-av_hr-88feb0b61b1485a8eff0710aa16ca233{\nmargin-top:20px;\nmargin-bottom:20px;\n}\n.hr.av-av_hr-88feb0b61b1485a8eff0710aa16ca233 .hr-inner{\nwidth:50px;\nborder-color:#40a8e4;\n}\n<\/style>\n<div  class='hr av-av_hr-88feb0b61b1485a8eff0710aa16ca233 hr-custom  avia-builder-el-2  el_after_av_heading  el_before_av_heading  hr-center hr-icon-no'><span class='hr-inner inner-border-av-border-fat'><span class=\"hr-inner-style\"><\/span><\/span><\/div>\n\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-av_heading-3a70d749e5ec73ca1e85f8eac8b804bf\">\n#top .av-special-heading.av-av_heading-3a70d749e5ec73ca1e85f8eac8b804bf{\npadding-bottom:10px;\nfont-size:26px;\n}\nbody .av-special-heading.av-av_heading-3a70d749e5ec73ca1e85f8eac8b804bf .av-special-heading-tag .heading-char{\nfont-size:25px;\n}\n#top #wrap_all .av-special-heading.av-av_heading-3a70d749e5ec73ca1e85f8eac8b804bf .av-special-heading-tag{\nfont-size:26px;\n}\n.av-special-heading.av-av_heading-3a70d749e5ec73ca1e85f8eac8b804bf .av-subheading{\nfont-size:15px;\n}\n\n@media only screen and (min-width: 480px) and (max-width: 767px){ \n#top #wrap_all .av-special-heading.av-av_heading-3a70d749e5ec73ca1e85f8eac8b804bf .av-special-heading-tag{\nfont-size:0.8em;\n}\n}\n\n@media only screen and (max-width: 479px){ \n#top #wrap_all .av-special-heading.av-av_heading-3a70d749e5ec73ca1e85f8eac8b804bf .av-special-heading-tag{\nfont-size:0.8em;\n}\n}\n<\/style>\n<div  class='av-special-heading av-av_heading-3a70d749e5ec73ca1e85f8eac8b804bf av-special-heading-h3 blockquote modern-quote modern-centered  avia-builder-el-3  el_after_av_hr  el_before_av_textblock  av-inherit-size'><h3 class='av-special-heading-tag'  itemprop=\"headline\"  >Over the course of your treatment, how satisfied were you with the following?<\/h3><div class=\"special-heading-border\"><div class=\"special-heading-inner-border\"><\/div><\/div><\/div>\n<section  class='av_textblock_section av-av_textblock-0366cc7376be6c9e82a3e9cc8987b64f'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});<\/script>\n                <div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_3' ><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_3' id='gform_3'  action='\/wp-json\/wp\/v2\/pages\/1191#gf_3' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_13\" class=\"gfield gfield--type-name gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_13\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_13'>\n                            \n                            <span id='input_3_13_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.3' id='input_3_13_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_13_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_13_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.6' id='input_3_13_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_13_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_3_14\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_14\" ><label class='gfield_label gform-field-label' for='input_3_14'>Therapist<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_3_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_1\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_1\" ><label class='gfield_label gform-field-label' >Convenience of the location of the office?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_1'>\n\t\t\t<li class='gchoice gchoice_3_1_0'>\n\t\t\t\t<input name='input_1' type='radio' value='Very Satisfied'  id='choice_3_1_0'    \/>\n\t\t\t\t<label for='choice_3_1_0' id='label_3_1_0' class='gform-field-label gform-field-label--type-inline'>Very Satisfied<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_1_1'>\n\t\t\t\t<input name='input_1' type='radio' value='Somewhat Satisfied'  id='choice_3_1_1'    \/>\n\t\t\t\t<label for='choice_3_1_1' id='label_3_1_1' class='gform-field-label gform-field-label--type-inline'>Somewhat Satisfied<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_1_2'>\n\t\t\t\t<input name='input_1' type='radio' value='Neutral'  id='choice_3_1_2'    \/>\n\t\t\t\t<label for='choice_3_1_2' id='label_3_1_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_1_3'>\n\t\t\t\t<input name='input_1' type='radio' value='Dissatisfied'  id='choice_3_1_3'    \/>\n\t\t\t\t<label for='choice_3_1_3' id='label_3_1_3' class='gform-field-label gform-field-label--type-inline'>Dissatisfied<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_2\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_2\" ><label class='gfield_label gform-field-label' >Getting through to the office by phone?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_2'>\n\t\t\t<li class='gchoice gchoice_3_2_0'>\n\t\t\t\t<input name='input_2' type='radio' value='Very Satisfied'  id='choice_3_2_0'    \/>\n\t\t\t\t<label for='choice_3_2_0' id='label_3_2_0' class='gform-field-label gform-field-label--type-inline'>Very Satisfied<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_2_1'>\n\t\t\t\t<input name='input_2' type='radio' value='Somewhat Satisfied'  id='choice_3_2_1'    \/>\n\t\t\t\t<label for='choice_3_2_1' id='label_3_2_1' class='gform-field-label gform-field-label--type-inline'>Somewhat Satisfied<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_2_2'>\n\t\t\t\t<input name='input_2' type='radio' value='Neutral'  id='choice_3_2_2'    \/>\n\t\t\t\t<label for='choice_3_2_2' id='label_3_2_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_2_3'>\n\t\t\t\t<input name='input_2' type='radio' value='Dissatisfied'  id='choice_3_2_3'    \/>\n\t\t\t\t<label for='choice_3_2_3' id='label_3_2_3' class='gform-field-label gform-field-label--type-inline'>Dissatisfied<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_3\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_3\" ><label class='gfield_label gform-field-label' >The courtesy and consideration provided by the office staff?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_3'>\n\t\t\t<li class='gchoice gchoice_3_3_0'>\n\t\t\t\t<input name='input_3' type='radio' value='Very Satisfied'  id='choice_3_3_0'    \/>\n\t\t\t\t<label for='choice_3_3_0' id='label_3_3_0' class='gform-field-label gform-field-label--type-inline'>Very Satisfied<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_3_1'>\n\t\t\t\t<input name='input_3' type='radio' value='Somewhat Satisfied'  id='choice_3_3_1'    \/>\n\t\t\t\t<label for='choice_3_3_1' id='label_3_3_1' class='gform-field-label gform-field-label--type-inline'>Somewhat Satisfied<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_3_2'>\n\t\t\t\t<input name='input_3' type='radio' value='Neutral'  id='choice_3_3_2'    \/>\n\t\t\t\t<label for='choice_3_3_2' id='label_3_3_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_3_3'>\n\t\t\t\t<input name='input_3' type='radio' value='Dissatisfied'  id='choice_3_3_3'    \/>\n\t\t\t\t<label for='choice_3_3_3' id='label_3_3_3' class='gform-field-label gform-field-label--type-inline'>Dissatisfied<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_4\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_4\" ><label class='gfield_label gform-field-label' >The ability to schedule a convenient appointment time?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_4'>\n\t\t\t<li class='gchoice gchoice_3_4_0'>\n\t\t\t\t<input name='input_4' type='radio' value='Very Satisfied'  id='choice_3_4_0'    \/>\n\t\t\t\t<label for='choice_3_4_0' id='label_3_4_0' class='gform-field-label gform-field-label--type-inline'>Very Satisfied<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_4_1'>\n\t\t\t\t<input name='input_4' type='radio' value='Somewhat Satisfied'  id='choice_3_4_1'    \/>\n\t\t\t\t<label for='choice_3_4_1' id='label_3_4_1' class='gform-field-label gform-field-label--type-inline'>Somewhat Satisfied<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_4_2'>\n\t\t\t\t<input name='input_4' type='radio' value='Neutral'  id='choice_3_4_2'    \/>\n\t\t\t\t<label for='choice_3_4_2' id='label_3_4_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_4_3'>\n\t\t\t\t<input name='input_4' type='radio' value='Dissatisfied'  id='choice_3_4_3'    \/>\n\t\t\t\t<label for='choice_3_4_3' id='label_3_4_3' class='gform-field-label gform-field-label--type-inline'>Dissatisfied<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_5\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_5\" ><label class='gfield_label gform-field-label' >Length of time in waiting room?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_5'>\n\t\t\t<li class='gchoice gchoice_3_5_0'>\n\t\t\t\t<input name='input_5' type='radio' value='Very Satisfied'  id='choice_3_5_0'    \/>\n\t\t\t\t<label for='choice_3_5_0' id='label_3_5_0' class='gform-field-label gform-field-label--type-inline'>Very Satisfied<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_5_1'>\n\t\t\t\t<input name='input_5' type='radio' value='Somewhat Satisfied'  id='choice_3_5_1'    \/>\n\t\t\t\t<label for='choice_3_5_1' id='label_3_5_1' class='gform-field-label gform-field-label--type-inline'>Somewhat Satisfied<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_5_2'>\n\t\t\t\t<input name='input_5' type='radio' value='Neutral'  id='choice_3_5_2'    \/>\n\t\t\t\t<label for='choice_3_5_2' id='label_3_5_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_5_3'>\n\t\t\t\t<input name='input_5' type='radio' value='Dissatisfied'  id='choice_3_5_3'    \/>\n\t\t\t\t<label for='choice_3_5_3' id='label_3_5_3' class='gform-field-label gform-field-label--type-inline'>Dissatisfied<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_6\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_6\" ><label class='gfield_label gform-field-label' >The information you were given about your condition and treatment plan?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_6'>\n\t\t\t<li class='gchoice gchoice_3_6_0'>\n\t\t\t\t<input name='input_6' type='radio' value='Very Satisfied'  id='choice_3_6_0'    \/>\n\t\t\t\t<label for='choice_3_6_0' id='label_3_6_0' class='gform-field-label gform-field-label--type-inline'>Very Satisfied<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_6_1'>\n\t\t\t\t<input name='input_6' type='radio' value='Somewhat Satisfied'  id='choice_3_6_1'    \/>\n\t\t\t\t<label for='choice_3_6_1' id='label_3_6_1' class='gform-field-label gform-field-label--type-inline'>Somewhat Satisfied<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_6_2'>\n\t\t\t\t<input name='input_6' type='radio' value='Neutral'  id='choice_3_6_2'    \/>\n\t\t\t\t<label for='choice_3_6_2' id='label_3_6_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_6_3'>\n\t\t\t\t<input name='input_6' type='radio' value='Dissatisfied'  id='choice_3_6_3'    \/>\n\t\t\t\t<label for='choice_3_6_3' id='label_3_6_3' class='gform-field-label gform-field-label--type-inline'>Dissatisfied<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_7\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_7\" ><label class='gfield_label gform-field-label' >Your primary therapist\/practitioner?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_7'>\n\t\t\t<li class='gchoice gchoice_3_7_0'>\n\t\t\t\t<input name='input_7' type='radio' value='Very Satisfied'  id='choice_3_7_0'    \/>\n\t\t\t\t<label for='choice_3_7_0' id='label_3_7_0' class='gform-field-label gform-field-label--type-inline'>Very Satisfied<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_7_1'>\n\t\t\t\t<input name='input_7' type='radio' value='Somewhat Satisfied'  id='choice_3_7_1'    \/>\n\t\t\t\t<label for='choice_3_7_1' id='label_3_7_1' class='gform-field-label gform-field-label--type-inline'>Somewhat Satisfied<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_7_2'>\n\t\t\t\t<input name='input_7' type='radio' value='Neutral'  id='choice_3_7_2'    \/>\n\t\t\t\t<label for='choice_3_7_2' id='label_3_7_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_7_3'>\n\t\t\t\t<input name='input_7' type='radio' value='Dissatisfied'  id='choice_3_7_3'    \/>\n\t\t\t\t<label for='choice_3_7_3' id='label_3_7_3' class='gform-field-label gform-field-label--type-inline'>Dissatisfied<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_8\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_8\" ><label class='gfield_label gform-field-label' >Your overall therapy\/care you received?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_8'>\n\t\t\t<li class='gchoice gchoice_3_8_0'>\n\t\t\t\t<input name='input_8' type='radio' value='Very Satisfied'  id='choice_3_8_0'    \/>\n\t\t\t\t<label for='choice_3_8_0' id='label_3_8_0' class='gform-field-label gform-field-label--type-inline'>Very Satisfied<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_8_1'>\n\t\t\t\t<input name='input_8' type='radio' value='Somewhat Satisfied'  id='choice_3_8_1'    \/>\n\t\t\t\t<label for='choice_3_8_1' id='label_3_8_1' class='gform-field-label gform-field-label--type-inline'>Somewhat Satisfied<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_8_2'>\n\t\t\t\t<input name='input_8' type='radio' value='Neutral'  id='choice_3_8_2'    \/>\n\t\t\t\t<label for='choice_3_8_2' id='label_3_8_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_8_3'>\n\t\t\t\t<input name='input_8' type='radio' value='Dissatisfied'  id='choice_3_8_3'    \/>\n\t\t\t\t<label for='choice_3_8_3' id='label_3_8_3' class='gform-field-label gform-field-label--type-inline'>Dissatisfied<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_9\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_9\" ><label class='gfield_label gform-field-label' >Your overall rating of this facility?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_9'>\n\t\t\t<li class='gchoice gchoice_3_9_0'>\n\t\t\t\t<input name='input_9' type='radio' value='Very Satisfied'  id='choice_3_9_0'    \/>\n\t\t\t\t<label for='choice_3_9_0' id='label_3_9_0' class='gform-field-label gform-field-label--type-inline'>Very Satisfied<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_9_1'>\n\t\t\t\t<input name='input_9' type='radio' value='Somewhat Satisfied'  id='choice_3_9_1'    \/>\n\t\t\t\t<label for='choice_3_9_1' id='label_3_9_1' class='gform-field-label gform-field-label--type-inline'>Somewhat Satisfied<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_9_2'>\n\t\t\t\t<input name='input_9' type='radio' value='Neutral'  id='choice_3_9_2'    \/>\n\t\t\t\t<label for='choice_3_9_2' id='label_3_9_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_9_3'>\n\t\t\t\t<input name='input_9' type='radio' value='Dissatisfied'  id='choice_3_9_3'    \/>\n\t\t\t\t<label for='choice_3_9_3' id='label_3_9_3' class='gform-field-label gform-field-label--type-inline'>Dissatisfied<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_10\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_10\" ><label class='gfield_label gform-field-label' >How would you describe your condition upon discharge?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_10'>\n\t\t\t<li class='gchoice gchoice_3_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='Much Improved'  id='choice_3_10_0'    \/>\n\t\t\t\t<label for='choice_3_10_0' id='label_3_10_0' class='gform-field-label gform-field-label--type-inline'>Much Improved<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='Improved'  id='choice_3_10_1'    \/>\n\t\t\t\t<label for='choice_3_10_1' id='label_3_10_1' class='gform-field-label gform-field-label--type-inline'>Improved<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_10_2'>\n\t\t\t\t<input name='input_10' type='radio' value='Unchanged'  id='choice_3_10_2'    \/>\n\t\t\t\t<label for='choice_3_10_2' id='label_3_10_2' class='gform-field-label gform-field-label--type-inline'>Unchanged<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_10_3'>\n\t\t\t\t<input name='input_10' type='radio' value='Worse'  id='choice_3_10_3'    \/>\n\t\t\t\t<label for='choice_3_10_3' id='label_3_10_3' class='gform-field-label gform-field-label--type-inline'>Worse<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_11\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_11\" ><label class='gfield_label gform-field-label' >Would you return to this facility for future cases?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_11'>\n\t\t\t<li class='gchoice gchoice_3_11_0'>\n\t\t\t\t<input name='input_11' type='radio' value='Yes'  id='choice_3_11_0'    \/>\n\t\t\t\t<label for='choice_3_11_0' id='label_3_11_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_11_1'>\n\t\t\t\t<input name='input_11' type='radio' value='No'  id='choice_3_11_1'    \/>\n\t\t\t\t<label for='choice_3_11_1' id='label_3_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_12\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_12\" ><label class='gfield_label gform-field-label' >Would you refer a family member or a friend to our facility?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_12'>\n\t\t\t<li class='gchoice gchoice_3_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='Yes'  id='choice_3_12_0'    \/>\n\t\t\t\t<label for='choice_3_12_0' id='label_3_12_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice 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name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_3' value='WyJbXSIsIjg0ZWZiMDY4OWI4ODg0ZWYwNzY5ZTQ4MTEyMTI4YWZmIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_3' id='gform_target_page_number_3' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_3' id='gform_source_page_number_3' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"92\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_3' id='gform_ajax_frame_3' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 3, 'https:\/\/lowcountrypt.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_3').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_3');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_3').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! 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