Endocrinology , Featured , Issues in Endocrinology

Canine Hypothyroidism: Diagnosis and Treatment

Johanna Heseltine DVM, MS, DACVIM (Small Animal Internal Medicine), Texas A&M University College of Veterinary Medicine & Biomedical Sciences, College Station, Texas

Dr. Heseltine is a clinical assistant professor at Texas A&M University. She received her DVM from the University of Saskatchewan and then completed a rotating small animal internship at the University of Prince Edward Island. She completed her master’s degree and small animal internal medicine residency at Virginia Tech and is a Diplomate of the American College of Veterinary Medicine (small animal internal medicine). Dr. Heseltine has held faculty and teaching positions and worked in private specialty practice. She is interested in a broad range of internal medicine disorders of small animals.

Canine Hypothyroidism: Diagnosis and Treatment
FIRST STEP: MAKING AN ACCURATE DIAGNOSIS Veterinarians find diagnosing hypothyroidism—which can affect any breed—is tricky because many canine diseases mimic the disorder. Photo Credit: shutterstock.com/taro911
  • 253
  •  
  •  
  •  
  •  
  •  
  •  
    253
    Shares

Hypothyroidism is a common endocrine disease of dogs. It occurs when the thyroid glands fail to produce adequate amounts of the hormones thyroxine (T4) and triiodothyronine (T3). Primary hypothyroidism resulting from idiopathic thyroid gland atrophy or immune-mediated lymphocytic thyroiditis is the most common diagnosis. Uncommon causes of canine hypothyroidism include congenital disease resulting from dyshormonogenesis of thyroid hormone, abnormal thyroid-stimulating hormone (TSH) production, or abnormal thyroid gland development.1

Thyroid hormones are involved in a wide variety of metabolic processes, and low thyroid hormone levels result in a constellation of clinical signs and laboratory abnormalities that characterize hypothyroidism. Multiple hormone tests are required to make a diagnosis. The diagnosis should never be based on low T4 concentration as a sole finding.

CLINICAL PRESENTATION

Hypothyroidism typically affects middle-aged dogs, although it has been reported in younger and older dogs. Any breed can be affected. Clinical signs (BOX 1) may be nonspecific, which can result in overdiagnosis of this disorder; lethargy and weight gain are common.2,3 Clinical signs may have an insidious onset and may not be noticed by the owner. Hypothyroidism often causes hair coat changes, including bilaterally symmetric, nonpruritic alopecia over the trunk or areas of wear, post-clipping alopecia, and a dull, lusterless hair coat (FIGURE 1). Skin changes may include scaling, seborrhea, hyperpigmentation, and recurrent infections (pyoderma or otitis externa).2,3

Rare clinical signs and syndromes that have been associated with hypothyroidism include megaesophagus, vestibular dysfunction, facial nerve paralysis, and atherosclerosis.4,5,8

BOX 1 Clinical Signs Commonly Associated With Canine Hypothyroidism2-7
  • Signs related to decreased metabolic rate
    • Lethargy or dull mentation
    • Inactivity or unwillingness to exercise
    • Weight gain
    • Cold intolerance or heat seeking
  • Dermatologic changes
    • Symmetric, nonpruritic hair loss
    • Post-clipping alopecia
    • Dry, dull hair coat
    • Scaling
    • Hyperpigmentation
    • Recurrent pyoderma or otitis externa

Uncommon

  • Incoordination
  • Ocular signs
    • Lipid corneal deposits
  • Peripheral nervous system signs
    • Facial nerve paralysis
    • Laryngeal paralysis
    • Polyneuropathy
    • Other
  • Vestibular signs
  • Megaesophagus or esophageal dysmotility
  • Cardiovascular abnormalities
    • Bradycardia
    • Exacerbation of other cardiac signs
    • Atherosclerosis
  • Reproductive effects
    • Periparturient mortality
    • Lower birth weights
  • Myxedema coma
    • Depressed mental status
    • Altered thermoregulation
    • Bradycardia
    • Hypoventilation
    • Thickened skin

DIAGNOSTIC PROCESS

Dogs should be tested for hypothyroidism only when the disease is strongly suspected based on the patient’s history and physical examination findings (BOX 1). Complete blood count and serum biochemistry panel results may heighten clinical suspicion for hypothyroidism. Hypothyroidism can be misdiagnosed when testing is performed only because a dog is overweight or because a T4 concentration is included with a standard biochemistry panel.

A stepwise approach is helpful in accurately diagnosing canine hypothyroidism (FIGURE 2).

Step 1: Evaluate Minimum Database Results for Supportive Findings

Results from a complete blood count, serum biochemistry panel, and urinalysis are helpful to rule out concurrent disorders that could affect thyroid test results. However, none of the abnormal results that may be seen on these tests are specific for hypothyroidism.

Approximately 75% of hypothyroid dogs have elevated cholesterol levels.2,3 While mild hypercholesterolemia alone should not prompt testing for hypothyroidism, it supports a suspicion of hypothyroidism. Liver enzymes may be mildly elevated. A mild, nonregenerative anemia is present in about 30% to 40% of hypothyroid dogs.2,3 The urinalysis typically shows no abnormalities. Dilute urine, if present, should prompt investigation for concurrent illness or another cause of clinical signs.

Step 2: Screen With a T4 Concentration

Total T4 concentration is a useful screening test for hypothyroidism. The sensitivity of this test for the diagnosis of canine hypothyroidism is reported to be 89% to 100%.9-12 If the T4 concentration is well within reference range, it is very likely the dog is euthyroid and further thyroid testing is not required. Free T4 (fT4) and thyroid-stimulating hormone (TSH) are evaluated only if the T4 concentration is low (FIGURE 2). Combined T4, fT4, and TSH testing is not recommended at this stage and may add unnecessary expense since a normal T4 concentration effectively rules out hypothyroidism.

However, a T4 concentration below reference range is not diagnostic for hypothyroidism. In addition to normal daily fluctuations, several medications have been demonstrated to lower the serum T4 concentration of dogs (BOX 2), and some also affect fT4 and TSH concentrations. Certain drugs, such as trimethoprim–sulfamethoxazole, can have direct effects on the pituitary–thyroid axis and result in hypothyroidism.13 Furthermore, nonthyroidal illnesses can alter thyroid hormone metabolism and result in the euthyroid sick syndrome (BOX 3). Concentrations of fT4 are less likely to be affected by concurrent illness, but if the illness is severe enough, fT4 can also be low.21,22 Therefore, thyroid testing should not be performed in dogs that are systemically ill. If a dog with a concurrent illness is tested for hypothyroidism, test results should be interpreted with caution.

BOX 2 Drugs That Alter Canine Thyroid Hormone Function or Test Results13-20
  • Prednisone (high dose)
  • Phenobarbital
  • Trimethoprim–sulfamethoxazole
  • Aspirin (high dose)
  • Clomipramine
  • Thyroxine supplementation

BOX 3 Euthyroid Sick Syndrome
This syndrome refers to a condition in which nonthyroidal illness suppresses the concentration of circulating thyroid hormones. The mechanism is complex and likely involves changes in hormone distribution and metabolism and altered binding of hormones to proteins.

Because diagnosing hypothyroidism is not an emergency, sending samples out to a reference laboratory is advisable. Since additional confirmatory tests are required, it is helpful to collect and hold extra serum when collecting for the T4 test.

It is important to remember that “normal” reference ranges for T4 do not apply to sighthounds, as healthy dogs of these breeds have lower T4 concentrations than other breeds.23,24

Step 3: Confirm With an fT4 or TSH Concentration

When a dog suspected to have hypothyroidism has a low total T4 concentration, fT4 and/or TSH concentrations must be evaluated to help confirm or refute the diagnosis (TABLE 1). If the TSH concentration is high, hypothyroidism can be diagnosed. However, 13% to 38% of hypothyroid dogs have normal TSH concentrations,10-12,25 so a normal TSH concentration does not exclude the diagnosis. Because of this limitation, it is often helpful to evaluate fT4 and TSH simultaneously as confirmatory tests. If the fT4 is low, a diagnosis of hypothyroidism can be made.

If T4 is low and fT4 is within reference range, hypothyroidism cannot be diagnosed, and the clinician should consider other differentials for the dog’s clinical signs.

T3 concentrations vary widely and are not diagnostically useful.

TREATMENT

Initiating Therapy

Studies have shown that most dogs can be regulated with once-daily levothyroxine,26,27 usually initiated at 0.02 mg/kg PO q24h. Some clinicians begin with twice-daily administration of levothyroxine (0.02 mg/kg PO q12h) and attempt to reduce the dosing to once daily, once clinical signs are well controlled. Lethargy often improves after a few weeks. Most clinical signs improve within 4 to 6 weeks, although dermatologic changes take months to resolve.

Monitoring and Adjusting Therapy

After 4 weeks of therapy, blood is collected 4 to 6 hours post-pill for T4 measurement. (T4 can be measured as early as 2 weeks after starting or adjusting therapy,26 but waiting until 4 weeks allows for assessment of improvement in clinical signs at the same visit.) The post-pill T4 concentration should be at the upper end of the reference range or slightly above (<6 mcg/dL). Laboratory reference ranges for “initial” T4 concentrations and “post-pill” concentrations may be different, so careful sample labeling and interpretation are important.

If the post-pill T4 concentration is below the target concentration, the dose of levothyroxine should be increased by 25%. The T4 concentration is then rechecked in 2 to 4 weeks. The dose is gradually increased until the post-pill T4 concentration is within the target range. Similarly, if the post-pill T4 concentration is too high, the dose should be decreased by 25% and the concentration rechecked. Once an effective dose has been established, the interval between monitoring visits is increased to every 6 months.

Approximately 75% of hypothyroid dogs have elevated cholesterol levels.2,3 While mild hypercholesterolemia alone should not prompt testing for hypothyroidism, it supports a suspicion of hypothyroidism.

Treatment Failure and Adverse Effects

Treatment failure is uncommon. Possible reasons for failure to achieve the targeted T4 concentration include owner noncompliance in administering medication or patient refusal to swallow the pills. Variable gastrointestinal absorption of levothyroxine is also considered to be a possible cause.28 If a target post-pill T4 concentration has been achieved and clinical signs are not controlled, the dosing frequency should be increased to twice daily. Additionally, the diagnosis of hypothyroidism should be reconsidered. If the diagnosis of hypothyroidism is definitive and the dog’s T4 concentration is well controlled, consider whether a concurrent disorder could be causing clinical signs.

Dogs are generally resistant to the effects of excessive levothyroxine supplementation. However, clinical signs such as polyuria/polydipsia and hyperactivity may develop.26

SUMMARY

Thyroid testing should be carried out only when patients are suspected of having thyroid disease. Measurement of T4 concentration is helpful to rule out hypothyroidism but should not be solely relied on to confirm the diagnosis. Combined testing that includes the serum T4 concentration along with fT4 and/or TSH levels is needed for definitive diagnosis and will help decrease the possibility for misdiagnosis of hypothyroidism. Since lifelong therapy is required, it is appropriate to achieve a definitive diagnosis before starting therapy.

References

  1. Graham PA, Refsal KR, Nachreiner RF. Etiopathologic findings in canine hypothyroidism. Vet Clin North Am Small Anim Pract 2007;37(4):617-631.
  2. Panciera DL. Hypothyroidism in dogs: 66 cases (1987-1992). JAVMA 1994;204(5):761-767.
  3. Dixon RM, Reid SW, Mooney CT. Epidemiological, clinical, haematological and biochemical characteristics of canine hypothyroidism. Vet Rec 1999;145(17):481-487.
  4. Jaggy A, Oliver JE, Ferguson DC, et al. Neurological manifestations of hypothyroidism: a retrospective study of 29 dogs. J Vet Intern Med 1994;8(5):328-336.
  5. Higgins MA, Rossmeisl JH, Panceria DL. Hypothyroid-associated central vestibular disease in 10 dogs: 1999-2005. J Vet Intern Med 2008;20(6):1363-1369.
  6. Panciera DL, Purswell BJ, Kolster KA, et al. Reproductive effects of prolonged experimentally induced hypothyroidism in bitches. J Vet Intern Med 2012;26(2):326-333.
  7. Finora K, Greco D. Hypothyroidism and myxedema coma. Comp Cont Educ Pract Vet 2007;29(1):19-32.
  8. Hess RS, Kass PH, Van Winkle TJ. Association between diabetes mellitus, hypothyroidism or hyperadrenocorticism, and atherosclerosis in dogs. J Vet Intern Med 2003;17(4):489-494.
  9. Nelson RW, Ihle SL, Feldman EC, et al. Serum free thyroxine concentration in healthy dogs, dogs with hypothyroidism, and euthyroid dogs with concurrent illness. JAVMA 1991;198(8)1401-1407.
  10. Peterson ME, Melian C, Nichols R. Measurement of serum total thyroxine, triiodothyronine, free thyroxine, and thyrotropin concentration for diagnosis of hypothyroidism in dogs. JAVMA 1997;211(11):1396-1402.
  11. Scott-Moncrieff JC, Nelson RW, Bruner JM, et al. Comparison of serum concentrations of thyroid-stimulating hormone in healthy dogs, hypothyroid dogs, and euthyroid dogs with concurrent illness. JAVMA 1998;212(3):387-391.
  12. Dixon RM, Mooney CT. Evaluation of serum free thyroxine and thyrotropin concentrations in the diagnosis of canine hypothyroidism. J Small Anim Pract 1999;40(2):72-78.
  13. Hall IA, Campbell KL, Chambers MD, et al. Effect of trimethoprim/sulfamethoxazole on thyroid function in dogs with pyoderma. JAVMA 1993;202(12):1959-1962.
  14. Daminet S, Paradis M, Refsal KR, et al. Short-term influence of prednisone and phenobarbital on thyroid function in euthyroid dogs. Can Vet J 1999;40(6):411-415.
  15. Gaskill CL, Burton SA, Gelens HC, et al. Effects of phenobarbital treatment on serum thyroxine and thyroid-stimulating hormone concentrations in epileptic dogs. JAVMA 1999;215(4):489-496.
  16. Muller PB, Wolfsheimer KJ, Taboada J, et al. Effects of long-term phenobarbital treatment on the thyroid and adrenal axis and adrenal function tests in dogs. J Vet Intern Med 2000;14(2):157-164.
  17. Williamson NL, Frank LA, Hnilica KA. Effects of short-term trimethoprim-sulfamethoxazole administration on thyroid function in dogs. JAVMA 2002;221(6):802-806.
  18. Frank LA, Hnilica KA, May ER, et al. Effects of sulfamethoxazole-trimethoprim on thyroid function in dogs. Am J Vet Res 2005;66(2):256-259.
  19. Daminet S, Courbels S, Duchateau L, et al. Influence of acetylsalicylic acid and ketoprofen on canine thyroid function tests. Vet J 2003;166(3):224-232.
  20. Gulikers KP, Panceria DL. Evaluation of the effects of clomipramine on canine thyroid function tests. J Vet Intern Med 2003;17(1):44-49.
  21. Kantrowitz LB, Peterson ME, Melian C, et al. Serum total thyroxine, total triiodothyronine, free thyroxine, and thyrotropin concentrations in dogs with nonthyroidal disease. JAVMA 2001;219(6):765-769.
  22. Torres SM, Feeney DA, Lekcharoensuk C, et al. Comparison of colloid, thyroid follicular endothelium, and thyroid hormone concentrations in healthy and severely sick dogs. JAVMA 2003;222(8):1079-1085.
  23. Shiel RE, Sist MD, Nachreiner RF, et al. Assessment of criteria used by veterinary practitioners to diagnose hypothyroidism in sighthounds and investigation of serum thyroid hormone concentrations in healthy Salukis. JAVMA 2010;236(3):302-308.
  24. Gaughan KR, Bruyette DS. Thyroid function testing in greyhounds. Am J Vet Res 2001;62(7):1130-1133.
  25. Ramsey IK, Evans H, Herrtage ME. Thyroid-stimulating hormone and total thyroxine concentrations in euthyroid, sick euthyroid, and hypothyroid dogs. J Small Anim Pract 1997;38(12):540-545.
  26. Dixon RM, Reid SWJ, Mooney CT. Treatment and therapeutic monitoring of canine hypothyroidism. J Small Anim Pract 2006;43(8):334-340.
  27. Lewis VA, Morrow CMK, Jacobsen JA, et al. A pivotal field study to support the registration of levothyroxine sodium tablets for canine hypothyroidism. JAAHA 2018;54(4):201-208.
  28. Nachreimer RF, Refsal KR. Radioimmunoassay monitoring of thyroid hormone concentrations in dogs on thyroid replacement therapy: 2,674 cases (1985-1987). JAVMA 1992;201(4):623-629.

DMCA.com Protection Status
[gravityform id="6" title="false" description="false"]
<div class='gf_browser_unknown gform_wrapper' id='gform_wrapper_6' style='display:none'><form method='post' enctype='multipart/form-data' id='gform_6' action='/canine-hypothyroidism-diagnosis-and-treatment/'> <div class='gform_body'><ul id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below'><li id='field_6_1' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' >Name<span class='gfield_required'>*</span></label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_6_1'> <span id='input_6_1_3_container' class='name_first' > <input type='text' name='input_1.3' id='input_6_1_3' value='' aria-label='First name' aria-required="true" aria-invalid="false" /> <label for='input_6_1_3' >First</label> </span> <span id='input_6_1_6_container' class='name_last' > <input type='text' name='input_1.6' id='input_6_1_6' value='' aria-label='Last name' aria-required="true" aria-invalid="false" /> <label for='input_6_1_6' >Last</label> </span> </div></li><li id='field_6_2' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_2' >Email<span class='gfield_required'>*</span></label><div class='ginput_container ginput_container_email'> <input name='input_2' id='input_6_2' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id='field_6_7' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_7' >Profession / Role<span class='gfield_required'>*</span></label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_6_7' class='medium gfield_select' aria-required="true" aria-invalid="false"><option value='Veterinarian' >Veterinarian</option><option value='Veterinary Nurse / Technician' >Veterinary Nurse / Technician</option><option value='Practice Manager / Veterinary Assistant / Support Staff' >Practice Manager / Veterinary Assistant / Support Staff</option><option value='Student (Veterinarian or Veterinary Nurse)' >Student (Veterinarian or Veterinary Nurse)</option><option value='Other' >Other</option></select></div></li><li id='field_6_20' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><br></li><li id='field_6_15' class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' >Inbox Preferences</label><div class='gfield_description' id='gfield_description_6_15'>Customize your inbox by selecting the areas you are most interested in. </div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_15'><li class='gchoice_6_15_1'> <input name='input_15.1' type='checkbox' value='NAVC Better Care Weekly&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;A weekly roundup of the new and noteworthy innovations and educational opportunities in the veterinary industry.&lt;/div&gt;' checked='checked' id='choice_6_15_1' /> <label for='choice_6_15_1' id='label_6_15_1'>NAVC Better Care Weekly<br><div style="font-size: 12px; color: #808080;">A weekly roundup of the new and noteworthy innovations and educational opportunities in the veterinary industry.</div></label> </li><li class='gchoice_6_15_2'> <input name='input_15.2' type='checkbox' value='Today&#039;s Veterinary Business eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Covers topics relating to practice management, financial metrics, marketing, retailing and merchandising, and industry news.&lt;/div&gt;' id='choice_6_15_2' /> <label for='choice_6_15_2' id='label_6_15_2'>Today's Veterinary Business eNewsletter<br><div style="font-size: 12px; color: #808080;">Covers topics relating to practice management, financial metrics, marketing, retailing and merchandising, and industry news.</div></label> </li><li class='gchoice_6_15_3'> <input name='input_15.3' type='checkbox' value='Today&#039;s Veterinary Nurse eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Provides practical, peer-reviewed companion animal educational CE for veterinary nurses, technicians and assistants.&lt;/div&gt;' id='choice_6_15_3' /> <label for='choice_6_15_3' id='label_6_15_3'>Today's Veterinary Nurse eNewsletter<br><div style="font-size: 12px; color: #808080;">Provides practical, peer-reviewed companion animal educational CE for veterinary nurses, technicians and assistants.</div></label> </li><li class='gchoice_6_15_4'> <input name='input_15.4' type='checkbox' value='Today&#039;s Veterinary Practice eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Provides practical, peer-reviewed articles focused on the latest diagnostic and treatment techniques to enhance your knowledge and confidence.&lt;/div&gt;' id='choice_6_15_4' /> <label for='choice_6_15_4' id='label_6_15_4'>Today's Veterinary Practice eNewsletter<br><div style="font-size: 12px; color: #808080;">Provides practical, peer-reviewed articles focused on the latest diagnostic and treatment techniques to enhance your knowledge and confidence.</div></label> </li><li class='gchoice_6_15_5'> <input name='input_15.5' type='checkbox' value='VetFolio eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Discover online CE resources offered in a variety of formats including videos, podcasts, webinars and more.&lt;/div&gt;' id='choice_6_15_5' /> <label for='choice_6_15_5' id='label_6_15_5'>VetFolio eNewsletter<br><div style="font-size: 12px; color: #808080;">Discover online CE resources offered in a variety of formats including videos, podcasts, webinars and more.</div></label> </li><li class='gchoice_6_15_6'> <input name='input_15.6' type='checkbox' value='Partner Emails&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Exclusive deals and information from our partners.&lt;/div&gt;' id='choice_6_15_6' /> <label for='choice_6_15_6' id='label_6_15_6'>Partner Emails<br><div style="font-size: 12px; color: #808080;">Exclusive deals and information from our partners.</div></label> </li></ul></div></li><li id='field_6_19' class='gfield gfield_html gfield_html_formatted field_sublabel_below field_description_below gfield_visibility_visible' ><br></li><li id='field_6_22' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' >Do you want to be added to our postal mailing list?</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_22'><li class='gchoice_6_22_1'> <input name='input_22.1' type='checkbox' value='Yes, I love mail!' id='choice_6_22_1' /> <label for='choice_6_22_1' id='label_6_22_1'>Yes, I love mail!</label> </li><li class='gchoice_6_22_2'> <input name='input_22.2' type='checkbox' value='No thank you.' id='choice_6_22_2' /> <label for='choice_6_22_2' id='label_6_22_2'>No thank you.</label> </li></ul></div></li><li id='field_6_10' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' >Please provide your mailing address below.<span class='gfield_required'>*</span></label> <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_6_10' > <span class='ginput_full address_line_1' id='input_6_10_1_container' > <input type='text' name='input_10.1' id='input_6_10_1' value='' aria-required="true"/> <label for='input_6_10_1' id='input_6_10_1_label' >Street Address</label> </span><span class='ginput_full address_line_2' id='input_6_10_2_container' > <input type='text' name='input_10.2' id='input_6_10_2' value='' /> <label for='input_6_10_2' id='input_6_10_2_label' >Address Line 2</label> </span><span class='ginput_left address_city' id='input_6_10_3_container' > <input type='text' name='input_10.3' id='input_6_10_3' value='' aria-required="true"/> <label for='input_6_10_3' id='input_6_10_3_label' >City</label> </span><span class='ginput_right address_state' id='input_6_10_4_container' > <input type='text' name='input_10.4' id='input_6_10_4' value='' aria-required="true"/> <label for='input_6_10_4' id='input_6_10_4_label' >State / Province / Region</label> </span><span class='ginput_left address_zip' id='input_6_10_5_container' > <input type='text' name='input_10.5' id='input_6_10_5' value='' aria-required="true"/> <label for='input_6_10_5' id='input_6_10_5_label' >ZIP / Postal Code</label> </span><span class='ginput_right address_country' id='input_6_10_6_container' > <select name='input_10.6' id='input_6_10_6' aria-required="true"><option value='' selected='selected'></option><option value='Afghanistan' >Afghanistan</option><option value='Åland Islands' >Åland Islands</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Congo, Republic of the' >Congo, Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Côte d&#039;Ivoire' >Côte d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Curaçao' >Curaçao</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard and McDonald Islands' >Heard and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macau' >Macau</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Korea' >North Korea</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Réunion' >Réunion</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Barthélemy' >Saint Barthélemy</option><option value='Saint Helena' >Saint Helena</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia' >South Georgia</option><option value='South Korea' >South Korea</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' >United States</option><option value='Uruguay' >Uruguay</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select> <label for='input_6_10_6' id='input_6_10_6_label' >Country</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li> </ul></div> <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_6' class='gform_button button' value='Sign Up' onclick='if(window["gf_submitting_6"]){return false;} window["gf_submitting_6"]=true; ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_6"]){return false;} window["gf_submitting_6"]=true; jQuery("#gform_6").trigger("submit",[true]); }' /> <input type='hidden' class='gform_hidden' name='is_submit_6' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='6' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_6' value='WyJbXSIsIjNkNTNhNjhlOThlOGY4N2JlZWZiNTRmZDhlZDQ5OWI3Il0=' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_6' id='gform_target_page_number_6' value='0' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_6' id='gform_source_page_number_6' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> </form> </div><script type='text/javascript'> jQuery(document).bind('gform_post_render', function(event, formId, currentPage){if(formId == 6) {gf_global["number_formats"][6] = {"1":{"price":false,"value":false},"2":{"price":false,"value":false},"7":{"price":false,"value":false},"20":{"price":false,"value":false},"15":{"price":false,"value":false},"19":{"price":false,"value":false},"22":{"price":false,"value":false},"10":{"price":false,"value":false}};if(window['jQuery']){if(!window['gf_form_conditional_logic'])window['gf_form_conditional_logic'] = new Array();window['gf_form_conditional_logic'][6] = { logic: { 10: {"field":{"actionType":"show","logicType":"any","rules":[{"fieldId":"22","operator":"is","value":"Yes, I love mail!"}]},"nextButton":null,"section":null} }, dependents: { 10: [10] }, animation: 1, defaults: {"1":{"1.2":"","1.3":"","1.4":"","1.6":"","1.8":""},"15":["choice_6_15_1"],"10":{"10.1":"","10.2":"","10.3":"","10.4":"","10.5":"","10.6":""}}, fields: {"1":[],"2":[],"7":[],"20":[],"15":[],"19":[],"22":[10],"10":[]} }; if(!window['gf_number_format'])window['gf_number_format'] = 'decimal_dot';jQuery(document).ready(function(){gf_apply_rules(6, [10], true);jQuery('#gform_wrapper_6').show();jQuery(document).trigger('gform_post_conditional_logic', [6, null, true]);} );} gformInitChosenFields('#input_6_7','No results matched');} } );jQuery(document).bind('gform_post_conditional_logic', function(event, formId, fields, isInit){gformInitChosenFields('#input_6_7','No results matched');} );</script><script type='text/javascript'> jQuery(document).ready(function(){jQuery(document).trigger('gform_post_render', [6, 1]) } ); </script>
MENU