{"id":32,"date":"2025-07-31T09:13:50","date_gmt":"2025-07-31T13:13:50","guid":{"rendered":"https:\/\/ontariobiobanks.ca\/?page_id=32"},"modified":"2025-09-05T16:04:15","modified_gmt":"2025-09-05T20:04:15","slug":"request-samples","status":"publish","type":"page","link":"https:\/\/ontariobiobanks.ca\/?page_id=32","title":{"rendered":"Start a Request"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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 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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)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_3' style='display:none'><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Request Form for Biospecimens, Data, and Services<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F32#gf_3' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_3_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_1'>\n                            \n                            <span id='input_3_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_3_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_3_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_3\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_3'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_3_3' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_4'>Institution\/Organization<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_3_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_5\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_5'>Study Description<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_5' id='input_3_5' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_3_18\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Disease<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_18'><div class='gchoice gchoice_3_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='Cancer'  id='choice_3_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_18_1' id='label_3_18_1' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='Blood Disorders'  id='choice_3_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_18_2' id='label_3_18_2' class='gform-field-label gform-field-label--type-inline'>Blood Disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='Healthy \/ Control'  id='choice_3_18_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_18_3' id='label_3_18_3' class='gform-field-label gform-field-label--type-inline'>Healthy \/ Control<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_18_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.4' type='checkbox'  value='Other (fill in box below)'  id='choice_3_18_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_18_4' id='label_3_18_4' class='gform-field-label gform-field-label--type-inline'>Other (fill in box below)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_6\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Species<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_6'><div class='gchoice gchoice_3_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='Human&gt;Adult'  id='choice_3_6_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_1' id='label_3_6_1' class='gform-field-label gform-field-label--type-inline'>Human&gt;Adult<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.2' type='checkbox'  value='Human&gt;Pediatric'  id='choice_3_6_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_2' id='label_3_6_2' class='gform-field-label gform-field-label--type-inline'>Human&gt;Pediatric<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.3' type='checkbox'  value='Companion Animal or Other (fill in box below)'  id='choice_3_6_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_3' id='label_3_6_3' class='gform-field-label gform-field-label--type-inline'>Companion Animal or Other (fill in box below)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_17\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cancer Disease Site(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_17'><div class='gchoice gchoice_3_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='Breast'  id='choice_3_17_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_1' id='label_3_17_1' class='gform-field-label gform-field-label--type-inline'>Breast<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='Central Nervous System'  id='choice_3_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_2' id='label_3_17_2' class='gform-field-label gform-field-label--type-inline'>Central Nervous System<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.3' type='checkbox'  value='Endocrine'  id='choice_3_17_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_3' id='label_3_17_3' class='gform-field-label gform-field-label--type-inline'>Endocrine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.4' type='checkbox'  value='Gastrointestinal'  id='choice_3_17_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_4' id='label_3_17_4' class='gform-field-label gform-field-label--type-inline'>Gastrointestinal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.5' type='checkbox'  value='Genito-Urinary'  id='choice_3_17_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_5' id='label_3_17_5' class='gform-field-label gform-field-label--type-inline'>Genito-Urinary<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.6' type='checkbox'  value='Gynecologic'  id='choice_3_17_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_6' id='label_3_17_6' class='gform-field-label gform-field-label--type-inline'>Gynecologic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.7' type='checkbox'  value='Head &amp; Neck'  id='choice_3_17_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_7' id='label_3_17_7' class='gform-field-label gform-field-label--type-inline'>Head &amp; Neck<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.8' type='checkbox'  value='Lung'  id='choice_3_17_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_8' id='label_3_17_8' class='gform-field-label gform-field-label--type-inline'>Lung<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.9' type='checkbox'  value='Lymphoma, leukemia, myeloma'  id='choice_3_17_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_9' id='label_3_17_9' class='gform-field-label gform-field-label--type-inline'>Lymphoma, leukemia, myeloma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.11' type='checkbox'  value='Ocular'  id='choice_3_17_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_11' id='label_3_17_11' class='gform-field-label gform-field-label--type-inline'>Ocular<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.12' type='checkbox'  value='Sarcoma'  id='choice_3_17_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_12' id='label_3_17_12' class='gform-field-label gform-field-label--type-inline'>Sarcoma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.13' type='checkbox'  value='Other (fill in box below)'  id='choice_3_17_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_13' id='label_3_17_13' class='gform-field-label gform-field-label--type-inline'>Other (fill in box below)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_7\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Retrospective Biospecimens<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_7'><div class='gchoice gchoice_3_7_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.1' type='checkbox'  value='Fresh Frozen Tumour'  id='choice_3_7_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_1' id='label_3_7_1' class='gform-field-label gform-field-label--type-inline'>Fresh Frozen Tumour<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.2' type='checkbox'  value='FFPE Tumour'  id='choice_3_7_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_2' id='label_3_7_2' class='gform-field-label gform-field-label--type-inline'>FFPE Tumour<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.3' type='checkbox'  value='Fresh Frozen Normal Adjacent'  id='choice_3_7_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_3' id='label_3_7_3' class='gform-field-label gform-field-label--type-inline'>Fresh Frozen Normal Adjacent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.4' type='checkbox'  value='FFPE Normal Adjacent'  id='choice_3_7_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_4' id='label_3_7_4' class='gform-field-label gform-field-label--type-inline'>FFPE Normal Adjacent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.5' type='checkbox'  value='EDTA Plasma'  id='choice_3_7_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_5' id='label_3_7_5' class='gform-field-label gform-field-label--type-inline'>EDTA Plasma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.6' type='checkbox'  value='EDTA Cell-Free Plasma'  id='choice_3_7_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_6' id='label_3_7_6' class='gform-field-label gform-field-label--type-inline'>EDTA Cell-Free Plasma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.7' type='checkbox'  value='EDTA Red Blood Cells'  id='choice_3_7_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_7' id='label_3_7_7' class='gform-field-label gform-field-label--type-inline'>EDTA Red Blood Cells<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.8' type='checkbox'  value='Streck Plasma'  id='choice_3_7_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_8' id='label_3_7_8' class='gform-field-label gform-field-label--type-inline'>Streck Plasma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.9' type='checkbox'  value='Streck Cell-Free Plasma'  id='choice_3_7_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_9' id='label_3_7_9' class='gform-field-label gform-field-label--type-inline'>Streck Cell-Free Plasma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.11' type='checkbox'  value='Buffy Coat'  id='choice_3_7_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_11' id='label_3_7_11' class='gform-field-label gform-field-label--type-inline'>Buffy Coat<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.12' type='checkbox'  value='White Blood Cell Pellet'  id='choice_3_7_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_12' id='label_3_7_12' class='gform-field-label gform-field-label--type-inline'>White Blood Cell Pellet<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.13' type='checkbox'  value='Serum'  id='choice_3_7_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_13' id='label_3_7_13' class='gform-field-label gform-field-label--type-inline'>Serum<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.14' type='checkbox'  value='Frozen Whole Blood'  id='choice_3_7_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_14' id='label_3_7_14' class='gform-field-label gform-field-label--type-inline'>Frozen Whole Blood<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.15' type='checkbox'  value='Dried Blood Spot Card'  id='choice_3_7_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_15' id='label_3_7_15' class='gform-field-label gform-field-label--type-inline'>Dried Blood Spot Card<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.16' type='checkbox'  value='Urine'  id='choice_3_7_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_16' id='label_3_7_16' class='gform-field-label gform-field-label--type-inline'>Urine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.17' type='checkbox'  value='Semen'  id='choice_3_7_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_17' id='label_3_7_17' class='gform-field-label gform-field-label--type-inline'>Semen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.18' type='checkbox'  value='Microbiome'  id='choice_3_7_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_18' id='label_3_7_18' class='gform-field-label gform-field-label--type-inline'>Microbiome<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.19' type='checkbox'  value='Ascites'  id='choice_3_7_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_19' id='label_3_7_19' class='gform-field-label gform-field-label--type-inline'>Ascites<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.21' type='checkbox'  value='Cerebrospinal Fluid'  id='choice_3_7_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_21' id='label_3_7_21' class='gform-field-label gform-field-label--type-inline'>Cerebrospinal Fluid<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.22' type='checkbox'  value='Dura mater'  id='choice_3_7_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_22' id='label_3_7_22' class='gform-field-label gform-field-label--type-inline'>Dura mater<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.23' type='checkbox'  value='Bone Marrow Aspirate'  id='choice_3_7_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_23' id='label_3_7_23' class='gform-field-label gform-field-label--type-inline'>Bone Marrow Aspirate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.24' type='checkbox'  value='Cryopreserved PBMC'  id='choice_3_7_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_24' id='label_3_7_24' class='gform-field-label gform-field-label--type-inline'>Cryopreserved PBMC<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.25' type='checkbox'  value='Buccal Swab'  id='choice_3_7_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_25' id='label_3_7_25' class='gform-field-label gform-field-label--type-inline'>Buccal Swab<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.26' type='checkbox'  value='DNA'  id='choice_3_7_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_26' id='label_3_7_26' class='gform-field-label gform-field-label--type-inline'>DNA<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.27' type='checkbox'  value='RNA'  id='choice_3_7_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_27' id='label_3_7_27' class='gform-field-label gform-field-label--type-inline'>RNA<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.28' type='checkbox'  value='Other (fill in box below)'  id='choice_3_7_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_28' id='label_3_7_28' class='gform-field-label gform-field-label--type-inline'>Other (fill in box below)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_8\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Custom Prospective Collections<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_8'><div class='gchoice gchoice_3_8_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.1' type='checkbox'  value='Fresh Tissue'  id='choice_3_8_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_1' id='label_3_8_1' class='gform-field-label gform-field-label--type-inline'>Fresh Tissue<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_8_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.2' type='checkbox'  value='Fresh Whole Blood'  id='choice_3_8_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_2' id='label_3_8_2' class='gform-field-label gform-field-label--type-inline'>Fresh Whole Blood<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_8_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.3' type='checkbox'  value='Other (fill in box below)'  id='choice_3_8_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_3' id='label_3_8_3' class='gform-field-label gform-field-label--type-inline'>Other (fill in box below)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_9\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Healthcare &amp; Other Data<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_9'><div class='gchoice gchoice_3_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Participant demographic information (age, sex)'  id='choice_3_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_1' id='label_3_9_1' class='gform-field-label gform-field-label--type-inline'>Participant demographic information (age, sex)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Race and Ethnicity'  id='choice_3_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_2' id='label_3_9_2' class='gform-field-label gform-field-label--type-inline'>Race and Ethnicity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Histology and diagnosis details'  id='choice_3_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_3' id='label_3_9_3' class='gform-field-label gform-field-label--type-inline'>Histology and diagnosis details<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.4' type='checkbox'  value='Sample collection details'  id='choice_3_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_4' id='label_3_9_4' class='gform-field-label gform-field-label--type-inline'>Sample collection details<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.5' type='checkbox'  value='Participant history'  id='choice_3_9_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_5' id='label_3_9_5' class='gform-field-label gform-field-label--type-inline'>Participant history<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.6' type='checkbox'  value='Biomarkers and gene status'  id='choice_3_9_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_6' id='label_3_9_6' class='gform-field-label gform-field-label--type-inline'>Biomarkers and gene status<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.7' type='checkbox'  value='Surgery information'  id='choice_3_9_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_7' id='label_3_9_7' class='gform-field-label gform-field-label--type-inline'>Surgery information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.8' type='checkbox'  value='Treatment and therapy information'  id='choice_3_9_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_8' id='label_3_9_8' class='gform-field-label gform-field-label--type-inline'>Treatment and therapy information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.9' type='checkbox'  value='Outcome and follow-up'  id='choice_3_9_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_9' id='label_3_9_9' class='gform-field-label gform-field-label--type-inline'>Outcome and follow-up<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.11' type='checkbox'  value='Digital images (H&amp;E, MRI, etc.)'  id='choice_3_9_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_11' id='label_3_9_11' class='gform-field-label gform-field-label--type-inline'>Digital images (H&amp;E, MRI, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.12' type='checkbox'  value='Other (fill in box below)'  id='choice_3_9_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_12' id='label_3_9_12' class='gform-field-label gform-field-label--type-inline'>Other (fill in box below)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_10\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_10'>Number of Cases Requested<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_10' id='input_3_10' type='number' step='any' min='0'  value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_3_10\" \/><div class='gfield_description instruction ' id='gfield_instruction_3_10'>Please enter a number greater than or equal to <strong>0<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_3_19\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Additional Services Requested<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_19'><div class='gchoice gchoice_3_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Prospective consenting \/ recruiting'  id='choice_3_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_19_1' id='label_3_19_1' class='gform-field-label gform-field-label--type-inline'>Prospective consenting \/ recruiting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='Project consulting \/ management'  id='choice_3_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_19_2' id='label_3_19_2' class='gform-field-label gform-field-label--type-inline'>Project consulting \/ management<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_19_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='End of project \/ Legacy planning'  id='choice_3_19_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_19_3' id='label_3_19_3' class='gform-field-label gform-field-label--type-inline'>End of project \/ Legacy planning<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_19_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.4' type='checkbox'  value='Tissue sectioning'  id='choice_3_19_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_19_4' id='label_3_19_4' class='gform-field-label gform-field-label--type-inline'>Tissue sectioning<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_19_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.5' type='checkbox'  value='Laser capture microdissection'  id='choice_3_19_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_19_5' id='label_3_19_5' class='gform-field-label gform-field-label--type-inline'>Laser capture microdissection<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_19_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.6' type='checkbox'  value='Tissue microarray creation'  id='choice_3_19_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_19_6' id='label_3_19_6' class='gform-field-label gform-field-label--type-inline'>Tissue microarray creation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_19_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.7' type='checkbox'  value='DNA extraction'  id='choice_3_19_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_19_7' id='label_3_19_7' class='gform-field-label gform-field-label--type-inline'>DNA extraction<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_19_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.8' type='checkbox'  value='RNA extraction'  id='choice_3_19_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_19_8' id='label_3_19_8' class='gform-field-label gform-field-label--type-inline'>RNA extraction<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_19_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.9' type='checkbox'  value='Protein extraction'  id='choice_3_19_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_19_9' id='label_3_19_9' class='gform-field-label gform-field-label--type-inline'>Protein extraction<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_19_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.11' type='checkbox'  value='Sequencing'  id='choice_3_19_11'   \/>\n\t\t\t\t\t\t\t\t<label 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