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content=\"AHNMASS8M\">\n<link rel=\"shortcut icon\" href=\"https:\/\/cdn.jotfor.ms\/favicon.ico\">\n<link rel=\"canonical\" href=\"https:\/\/alt.jotfor.ms\/80566391959876\" \/>\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0, maximum-scale=2.0, user-scalable=1\" \/>\n<meta name=\"HandheldFriendly\" content=\"true\" \/>\n<title>Asthma NZ Patient Referrals<\/title>\n<link href=\"https:\/\/alt.jotfor.ms\/static\/formCss.css?3.3.13713\" rel=\"stylesheet\" type=\"text\/css\" \/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/alt.jotfor.ms\/css\/styles\/nova.css?3.3.13713\" \/>\n<link type=\"text\/css\" media=\"print\" rel=\"stylesheet\" href=\"https:\/\/alt.jotfor.ms\/css\/printForm.css?3.3.13713\" \/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/alt.jotfor.ms\/themes\/CSS\/566a91c2977cdfcd478b4567.css?themeRevisionID=5da5f5afbdb53a02c94de4b1\"\/>\n<style type=\"text\/css\">\n    .form-label-left{\n        width:150px;\n    }\n    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     JotForm.description('input_4', 'If the patient is a child');\n      JotForm.description('input_24', 'If the patient is a child');\n\n JotForm.calendarMonths = [\"January\",\"February\",\"March\",\"April\",\"May\",\"June\",\"July\",\"August\",\"September\",\"October\",\"November\",\"December\"];\n JotForm.calendarDays = [\"Sunday\",\"Monday\",\"Tuesday\",\"Wednesday\",\"Thursday\",\"Friday\",\"Saturday\",\"Sunday\"];\n JotForm.calendarOther = {\"today\":\"Today\"};\n var languageOptions = document.querySelectorAll('#langList li'); \n for(var langIndex = 0; langIndex < languageOptions.length; langIndex++) { \n   languageOptions[langIndex].on('click', function(e) { setTimeout(function(){ JotForm.setCalendar(\"7\", true, {\"days\":{\"monday\":true,\"tuesday\":true,\"wednesday\":true,\"thursday\":true,\"friday\":true,\"saturday\":true,\"sunday\":true},\"future\":true,\"past\":true,\"custom\":false,\"ranges\":false,\"start\":\"\",\"end\":\"\"}); }, 0); });\n } \n JotForm.setCalendar(\"7\", true, {\"days\":{\"monday\":true,\"tuesday\":true,\"wednesday\":true,\"thursday\":true,\"friday\":true,\"saturday\":true,\"sunday\":true},\"future\":true,\"past\":true,\"custom\":false,\"ranges\":false,\"start\":\"\",\"end\":\"\"});\n      JotForm.description('input_8', 'Maori, NZ European, Samoan, Tongan, Chinese, Indian, etc');\n      JotForm.description('input_11', 'Self, GP, Hospital, etc');\n\n JotForm.calendarMonths = [\"January\",\"February\",\"March\",\"April\",\"May\",\"June\",\"July\",\"August\",\"September\",\"October\",\"November\",\"December\"];\n JotForm.calendarDays = [\"Sunday\",\"Monday\",\"Tuesday\",\"Wednesday\",\"Thursday\",\"Friday\",\"Saturday\",\"Sunday\"];\n JotForm.calendarOther = {\"today\":\"Today\"};\n var languageOptions = document.querySelectorAll('#langList li'); \n for(var langIndex = 0; langIndex < languageOptions.length; langIndex++) { \n   languageOptions[langIndex].on('click', function(e) { setTimeout(function(){ JotForm.setCalendar(\"12\", false, {\"days\":{\"monday\":true,\"tuesday\":true,\"wednesday\":true,\"thursday\":true,\"friday\":true,\"saturday\":true,\"sunday\":true},\"future\":true,\"past\":true,\"custom\":false,\"ranges\":false,\"start\":\"\",\"end\":\"\"}); }, 0); });\n } \n JotForm.setCalendar(\"12\", false, {\"days\":{\"monday\":true,\"tuesday\":true,\"wednesday\":true,\"thursday\":true,\"friday\":true,\"saturday\":true,\"sunday\":true},\"future\":true,\"past\":true,\"custom\":false,\"ranges\":false,\"start\":\"\",\"end\":\"\"});\n      JotForm.highlightInputs = false;\n      JotForm.alterTexts({\"nextButtonText\":\"Next\",\"prevButtonText\":\"Previous\",\"submitButtonText\":\"Submit\"});\n\tJotForm.clearFieldOnHide=\"disable\";\n      FormTranslation.init({\"detectUserLanguage\":\"1\",\"firstPageOnly\":\"0\",\"options\":\"English 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number\",\"type\":\"control_phone\"},{\"description\":\"\",\"name\":\"referrersEmail\",\"qid\":\"15\",\"subLabel\":\"example@example.com\",\"text\":\"Referrers email address\",\"type\":\"control_email\"},{\"description\":\"\",\"name\":\"gpAnd\",\"qid\":\"16\",\"text\":\"GP and Surgery name\",\"type\":\"control_fullname\"},{\"description\":\"\",\"name\":\"gpAnd17\",\"qid\":\"17\",\"text\":\"GP and Surgery Address\",\"type\":\"control_address\"},{\"description\":\"\",\"name\":\"diagnosis\",\"qid\":\"18\",\"subLabel\":\"\",\"text\":\"Diagnosis\",\"type\":\"control_textarea\"},null,{\"description\":\"\",\"name\":\"currentMedications\",\"qid\":\"20\",\"subLabel\":\"\",\"text\":\"Current medications and other relevant information\",\"type\":\"control_textarea\"},{\"description\":\"\",\"name\":\"verbalInformed\",\"qid\":\"21\",\"text\":\"Verbal informed consent for referral obtained\",\"type\":\"control_radio\"},{\"description\":\"\",\"name\":\"mobilePhone\",\"qid\":\"22\",\"text\":\"Mobile Phone Number\",\"type\":\"control_phone\"},{\"description\":\"\",\"name\":\"patientIs\",\"qid\":\"23\",\"text\":\"Patient is a child?\",\"type\":\"control_radio\"},{\"description\":\"If the patient is a child\",\"name\":\"caregiverName24\",\"qid\":\"24\",\"text\":\"Caregiver Name #2\",\"type\":\"control_fullname\"},null,{\"description\":\"\",\"name\":\"emailAddress26\",\"qid\":\"26\",\"subLabel\":\"example@example.com\",\"text\":\"Email address\",\"type\":\"control_email\"},{\"description\":\"\",\"name\":\"isIt27\",\"qid\":\"27\",\"text\":\"Is it a self-referral?\",\"type\":\"control_radio\"},{\"description\":\"\",\"name\":\"gender28\",\"qid\":\"28\",\"text\":\"Gender\",\"type\":\"control_radio\"},{\"description\":\"\",\"name\":\"reasonFor29\",\"qid\":\"29\",\"text\":\"Reason for referral\",\"type\":\"control_radio\"}]);\n   setTimeout(function() {\nJotForm.paymentExtrasOnTheFly([null,null,{\"name\":\"submit2\",\"qid\":\"2\",\"text\":\"Submit\",\"type\":\"control_button\"},{\"description\":\"\",\"name\":\"name\",\"qid\":\"3\",\"text\":\"Patients Name\",\"type\":\"control_fullname\"},{\"description\":\"If the patient is a child\",\"name\":\"caregiverName\",\"qid\":\"4\",\"text\":\"Caregiver Name #1\",\"type\":\"control_fullname\"},{\"description\":\"\",\"name\":\"typeA\",\"qid\":\"5\",\"subLabel\":\"\",\"text\":\"NHI Number\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"region\",\"qid\":\"6\",\"text\":\"Select a Region\",\"type\":\"control_radio\"},{\"description\":\"\",\"name\":\"date\",\"qid\":\"7\",\"text\":\"Date of Birth\",\"type\":\"control_datetime\"},{\"description\":\"Maori, NZ European, Samoan, Tongan, Chinese, Indian, etc\",\"name\":\"theEthnicity\",\"qid\":\"8\",\"subLabel\":\"\",\"text\":\"The ethnicity you identify with\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"address\",\"qid\":\"9\",\"text\":\"Address\",\"type\":\"control_address\"},{\"description\":\"\",\"name\":\"landlinePhone\",\"qid\":\"10\",\"text\":\"Landline Phone Number\",\"type\":\"control_phone\"},{\"description\":\"Self, GP, Hospital, etc\",\"name\":\"name11\",\"qid\":\"11\",\"text\":\"Referrers Name\",\"type\":\"control_fullname\"},{\"description\":\"\",\"name\":\"dateOf\",\"qid\":\"12\",\"text\":\"Date of referral\",\"type\":\"control_datetime\"},{\"description\":\"\",\"name\":\"referrersPostal\",\"qid\":\"13\",\"text\":\"Referrers postal address\",\"type\":\"control_address\"},{\"description\":\"\",\"name\":\"referrersPhone14\",\"qid\":\"14\",\"text\":\"Referrers phone number\",\"type\":\"control_phone\"},{\"description\":\"\",\"name\":\"referrersEmail\",\"qid\":\"15\",\"subLabel\":\"example@example.com\",\"text\":\"Referrers email 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type=\"hidden\" id=\"JWTContainer\" value=\"\" \/>\n  <input type=\"hidden\" id=\"cardinalOrderNumber\" value=\"\" \/>\n  <div role=\"main\" class=\"form-all\">\n    <link type=\"text\/css\" rel=\"stylesheet\" media=\"all\" href=\"https:\/\/alt.jotfor.ms\/wizards\/languageWizard\/custom-dropdown\/css\/lang-dd.css?3.3.13713\" \/>\n    <div class=\"cont\">\n      <input type=\"text\" id=\"input_language\" name=\"input_language\" style=\"display:none\" \/>\n      <div class=\"language-dd\" id=\"langDd\" style=\"display:none\">\n        <div class=\"dd-placeholder lang-emp\">\n          Language\n        <\/div>\n        <ul class=\"lang-list dn\" id=\"langList\">\n          <li data-lang=\"en-UK\" class=\"en-UK\">\n            English (UK)\n          <\/li>\n        <\/ul>\n      <\/div>\n    <\/div>\n    <script type=\"text\/javascript\" src=\"https:\/\/alt.jotfor.ms\/js\/formTranslation.v2.js?3.3.13713\"><\/script>\n    <ul class=\"form-section page-section\">\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_6\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_6\" for=\"input_6\">\n          Select a Region\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_6\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"3\" role=\"group\" aria-labelledby=\"label_6\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_6_0\" name=\"q6_region\" value=\"Auckland\" required=\"\" \/>\n              <label id=\"label_input_6_0\" for=\"input_6_0\"> Auckland <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              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class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"prefix_3\" name=\"q3_name[prefix]\" class=\"form-textbox\" size=\"4\" value=\"\" data-component=\"prefix\" aria-labelledby=\"label_3 sublabel_3_prefix\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"prefix_3\" id=\"sublabel_3_prefix\" style=\"min-height:13px\"> Prefix <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"first_3\" name=\"q3_name[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_3 sublabel_3_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_3\" id=\"sublabel_3_first\" style=\"min-height:13px\"> First Name <\/label>\n            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class=\"form-line form-line-column form-col-1 jf-required\" data-type=\"control_radio\" id=\"id_23\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_23\" for=\"input_23\">\n          Patient is a child?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_23\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_23\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_23_0\" name=\"q23_patientIs\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_23_0\" for=\"input_23_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_23_1\" name=\"q23_patientIs\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_23_1\" for=\"input_23_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required form-field-hidden\" style=\"display:none;\" data-type=\"control_fullname\" id=\"id_4\" data-compound-hint=\",,\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_4\" for=\"first_4\">\n          Caregiver Name #1\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_4\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"first_4\" name=\"q4_caregiverName[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_4 sublabel_4_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_4\" id=\"sublabel_4_first\" style=\"min-height:13px\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"last_4\" name=\"q4_caregiverName[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_4 sublabel_4_last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_4\" id=\"sublabel_4_last\" style=\"min-height:13px\"> Last Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"suffix_4\" name=\"q4_caregiverName[suffix]\" class=\"form-textbox\" size=\"4\" value=\"\" data-component=\"suffix\" aria-labelledby=\"label_4 sublabel_4_suffix\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"suffix_4\" id=\"sublabel_4_suffix\" style=\"min-height:13px\"> Relationship <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_fullname\" id=\"id_24\" data-compound-hint=\",,\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_24\" for=\"first_24\"> Caregiver Name #2 <\/label>\n        <div id=\"cid_24\" class=\"form-input-wide\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"first_24\" name=\"q24_caregiverName24[first]\" class=\"form-textbox\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_24 sublabel_24_first\" \/>\n              <label class=\"form-sub-label\" for=\"first_24\" id=\"sublabel_24_first\" style=\"min-height:13px\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"last_24\" name=\"q24_caregiverName24[last]\" class=\"form-textbox\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_24 sublabel_24_last\" \/>\n              <label class=\"form-sub-label\" for=\"last_24\" id=\"sublabel_24_last\" style=\"min-height:13px\"> Last Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"suffix_24\" name=\"q24_caregiverName24[suffix]\" class=\"form-textbox\" size=\"4\" value=\"\" data-component=\"suffix\" aria-labelledby=\"label_24 sublabel_24_suffix\" \/>\n              <label class=\"form-sub-label\" for=\"suffix_24\" id=\"sublabel_24_suffix\" style=\"min-height:13px\"> Relationship <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1\" data-type=\"control_textbox\" id=\"id_5\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_5\" for=\"input_5\"> NHI Number <\/label>\n        <div id=\"cid_5\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_5\" name=\"q5_typeA\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_5\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2 jf-required\" data-type=\"control_datetime\" id=\"id_7\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_7\" for=\"lite_mode_7\">\n          Date of Birth\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_7\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <div style=\"display:none\">\n              <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"day_7\" name=\"q7_date[day]\" size=\"2\" data-maxlength=\"2\" value=\"\" required=\"\" aria-labelledby=\"label_7 sublabel_7_day\" \/>\n                <span class=\"date-separate\" aria-hidden=\"true\">\n                  \u00a0-\n                <\/span>\n                <label class=\"form-sub-label\" for=\"day_7\" id=\"sublabel_7_day\" style=\"min-height:13px\"> Day <\/label>\n              <\/span>\n              <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"month_7\" name=\"q7_date[month]\" size=\"2\" data-maxlength=\"2\" value=\"\" required=\"\" aria-labelledby=\"label_7 sublabel_7_month\" \/>\n                <span class=\"date-separate\" aria-hidden=\"true\">\n                  \u00a0-\n                <\/span>\n                <label class=\"form-sub-label\" for=\"month_7\" id=\"sublabel_7_month\" style=\"min-height:13px\"> Month <\/label>\n              <\/span>\n              <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"year_7\" name=\"q7_date[year]\" size=\"4\" data-maxlength=\"4\" value=\"\" required=\"\" aria-labelledby=\"label_7 sublabel_7_year\" \/>\n                <label class=\"form-sub-label\" for=\"year_7\" id=\"sublabel_7_year\" style=\"min-height:13px\"> Year <\/label>\n              <\/span>\n            <\/div>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" class=\"form-textbox validate[required, limitDate, validateLiteDate]\" id=\"lite_mode_7\" size=\"12\" data-maxlength=\"12\" data-age=\"0\" value=\"\" required=\"\" data-format=\"ddmmyyyy\" data-seperator=\"-\" placeholder=\"dd-mm-yyyy\" aria-labelledby=\"label_7 sublabel_7_litemode\" \/>\n              <img class=\"showAutoCalendar\" alt=\"Pick a Date\" id=\"input_7_pick\" src=\"https:\/\/alt.jotfor.ms\/images\/calendar.png\" style=\"vertical-align:middle;margin-left:5px\" data-component=\"datetime\" aria-hidden=\"true\" \/>\n              <label class=\"form-sub-label\" for=\"lite_mode_7\" id=\"sublabel_7_litemode\" style=\"min-height:13px\"> Date <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <label class=\"form-sub-label\" for=\"input_7_pick\" style=\"border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap\"> Date Picker Icon <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_28\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_28\" for=\"input_28\">\n          Gender\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_28\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_28\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_28_0\" name=\"q28_gender28\" value=\"Male\" required=\"\" \/>\n              <label id=\"label_input_28_0\" for=\"input_28_0\"> Male <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_28_1\" name=\"q28_gender28\" value=\"Female\" required=\"\" \/>\n              <label id=\"label_input_28_1\" for=\"input_28_1\"> Female <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_28_2\" name=\"q28_gender28\" value=\"Unspecified\" required=\"\" \/>\n              <label id=\"label_input_28_2\" for=\"input_28_2\"> Unspecified <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <input type=\"radio\" class=\"form-radio-other form-radio validate[required]\" name=\"q28_gender28\" id=\"other_28\" value=\"other\" \/>\n              <label id=\"label_other_28\" style=\"text-indent:0\" for=\"other_28\">  <\/label>\n              <input type=\"text\" class=\"form-radio-other-input form-textbox\" name=\"q28_gender28[other]\" data-otherhint=\"Other\" placeholder=\"Other\" size=\"15\" id=\"input_28\" \/>\n              <br\/>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_8\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_8\" for=\"input_8\"> The ethnicity you identify with <\/label>\n        <div id=\"cid_8\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_8\" name=\"q8_theEthnicity\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_8\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_address\" id=\"id_9\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_9\" for=\"input_9_addr_line1\"> Address <\/label>\n        <div id=\"cid_9\" class=\"form-input-wide\">\n          <table summary=\"\" class=\"form-address-table\">\n            <tbody>\n              <tr>\n                <td colSpan=\"2\">\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_9_addr_line1\" name=\"q9_address[addr_line1]\" class=\"form-textbox form-address-line\" autoComplete=\"address-line1\" value=\"\" data-component=\"address_line_1\" aria-labelledby=\"label_9 sublabel_9_addr_line1\" \/>\n                    <label class=\"form-sub-label\" for=\"input_9_addr_line1\" id=\"sublabel_9_addr_line1\" style=\"min-height:13px\"> Street Address <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td colSpan=\"2\">\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_9_addr_line2\" name=\"q9_address[addr_line2]\" class=\"form-textbox form-address-line\" autoComplete=\"address-line2\" size=\"46\" value=\"\" data-component=\"address_line_2\" aria-labelledby=\"label_9 sublabel_9_addr_line2\" \/>\n                    <label class=\"form-sub-label\" for=\"input_9_addr_line2\" id=\"sublabel_9_addr_line2\" style=\"min-height:13px\"> Street Address Line 2 <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td>\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_9_city\" name=\"q9_address[city]\" class=\"form-textbox form-address-city\" autoComplete=\"address-level2\" size=\"21\" value=\"\" data-component=\"city\" aria-labelledby=\"label_9 sublabel_9_city\" \/>\n                    <label class=\"form-sub-label\" for=\"input_9_city\" id=\"sublabel_9_city\" style=\"min-height:13px\"> City\/Town <\/label>\n                  <\/span>\n                <\/td>\n                <td>\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_9_state\" name=\"q9_address[state]\" class=\"form-textbox form-address-state\" autoComplete=\"address-level1\" size=\"22\" value=\"\" data-component=\"state\" aria-labelledby=\"label_9 sublabel_9_state\" \/>\n                    <label class=\"form-sub-label\" for=\"input_9_state\" id=\"sublabel_9_state\" style=\"min-height:13px\"> Region <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td>\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_9_postal\" name=\"q9_address[postal]\" class=\"form-textbox form-address-postal\" autoComplete=\"postal-code\" size=\"10\" value=\"\" data-component=\"zip\" aria-labelledby=\"label_9 sublabel_9_postal\" \/>\n                    <label class=\"form-sub-label\" for=\"input_9_postal\" id=\"sublabel_9_postal\" style=\"min-height:13px\"> Post Code <\/label>\n                  <\/span>\n                <\/td>\n                <td style=\"display:none\">\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <select class=\"form-dropdown form-address-country noTranslate\" name=\"q9_address[country]\" id=\"input_9_country\" data-component=\"country\" aria-labelledby=\"label_9 sublabel_9_country\" autoComplete=\"new-password\">\n                      <option value=\"\"> Please Select <\/option>\n                      <option value=\"United States\"> United States <\/option>\n                      <option value=\"Afghanistan\"> Afghanistan <\/option>\n                      <option value=\"Albania\"> Albania <\/option>\n                      <option value=\"Algeria\"> Algeria <\/option>\n                      <option value=\"American Samoa\"> American Samoa <\/option>\n                      <option value=\"Andorra\"> Andorra <\/option>\n                      <option value=\"Angola\"> Angola <\/option>\n                      <option value=\"Anguilla\"> Anguilla <\/option>\n                      <option value=\"Antigua and Barbuda\"> Antigua and Barbuda <\/option>\n                      <option value=\"Argentina\"> Argentina <\/option>\n                      <option value=\"Armenia\"> Armenia <\/option>\n                      <option value=\"Aruba\"> Aruba <\/option>\n                      <option value=\"Australia\"> Australia <\/option>\n                      <option value=\"Austria\"> Austria <\/option>\n                      <option value=\"Azerbaijan\"> Azerbaijan <\/option>\n                      <option value=\"The Bahamas\"> The Bahamas <\/option>\n                      <option value=\"Bahrain\"> Bahrain <\/option>\n                      <option value=\"Bangladesh\"> Bangladesh <\/option>\n                      <option value=\"Barbados\"> Barbados <\/option>\n                      <option value=\"Belarus\"> Belarus <\/option>\n                      <option value=\"Belgium\"> Belgium <\/option>\n                      <option value=\"Belize\"> Belize <\/option>\n                      <option value=\"Benin\"> Benin <\/option>\n                      <option value=\"Bermuda\"> Bermuda <\/option>\n                      <option value=\"Bhutan\"> Bhutan <\/option>\n                      <option value=\"Bolivia\"> Bolivia <\/option>\n                      <option value=\"Bosnia and Herzegovina\"> Bosnia and Herzegovina <\/option>\n                      <option value=\"Botswana\"> Botswana <\/option>\n                      <option value=\"Brazil\"> Brazil <\/option>\n                      <option value=\"Brunei\"> Brunei <\/option>\n                      <option value=\"Bulgaria\"> Bulgaria <\/option>\n                      <option value=\"Burkina Faso\"> Burkina Faso <\/option>\n                      <option value=\"Burundi\"> Burundi <\/option>\n                      <option value=\"Cambodia\"> Cambodia <\/option>\n                      <option value=\"Cameroon\"> Cameroon <\/option>\n                      <option value=\"Canada\"> Canada <\/option>\n                      <option value=\"Cape Verde\"> Cape Verde <\/option>\n                      <option value=\"Cayman Islands\"> Cayman Islands <\/option>\n                      <option value=\"Central African Republic\"> Central African Republic <\/option>\n                      <option value=\"Chad\"> Chad <\/option>\n                      <option value=\"Chile\"> Chile <\/option>\n                      <option value=\"China\"> China <\/option>\n                      <option value=\"Christmas Island\"> Christmas Island <\/option>\n                      <option value=\"Cocos (Keeling) Islands\"> Cocos (Keeling) Islands <\/option>\n                      <option value=\"Colombia\"> Colombia <\/option>\n                      <option value=\"Comoros\"> Comoros <\/option>\n                      <option value=\"Congo\"> Congo <\/option>\n                      <option value=\"Cook Islands\"> Cook Islands <\/option>\n                      <option value=\"Costa Rica\"> Costa Rica <\/option>\n                      <option value=\"Cote d&#x27;Ivoire\"> Cote d&#x27;Ivoire <\/option>\n                      <option value=\"Croatia\"> Croatia <\/option>\n                      <option value=\"Cuba\"> Cuba <\/option>\n                      <option value=\"Cyprus\"> Cyprus <\/option>\n                      <option value=\"Czech Republic\"> Czech Republic <\/option>\n                      <option value=\"Democratic Republic of the Congo\"> Democratic Republic of the Congo <\/option>\n                      <option value=\"Denmark\"> Denmark <\/option>\n                      <option value=\"Djibouti\"> Djibouti <\/option>\n                      <option value=\"Dominica\"> Dominica <\/option>\n                      <option value=\"Dominican Republic\"> Dominican Republic <\/option>\n                      <option value=\"Ecuador\"> Ecuador <\/option>\n                      <option value=\"Egypt\"> Egypt <\/option>\n                      <option value=\"El Salvador\"> El Salvador <\/option>\n                      <option value=\"Equatorial Guinea\"> Equatorial Guinea <\/option>\n                      <option value=\"Eritrea\"> Eritrea <\/option>\n                      <option value=\"Estonia\"> Estonia <\/option>\n                      <option value=\"Ethiopia\"> Ethiopia <\/option>\n                      <option value=\"Falkland Islands\"> Falkland Islands <\/option>\n                      <option value=\"Faroe Islands\"> Faroe Islands <\/option>\n                      <option value=\"Fiji\"> Fiji <\/option>\n                      <option value=\"Finland\"> Finland <\/option>\n                      <option value=\"France\"> France <\/option>\n                      <option value=\"French Polynesia\"> French Polynesia <\/option>\n                      <option value=\"Gabon\"> Gabon <\/option>\n                      <option value=\"The Gambia\"> The Gambia <\/option>\n                      <option value=\"Georgia\"> Georgia <\/option>\n                      <option value=\"Germany\"> Germany <\/option>\n                      <option value=\"Ghana\"> Ghana <\/option>\n                      <option value=\"Gibraltar\"> Gibraltar <\/option>\n                      <option value=\"Greece\"> Greece <\/option>\n                      <option value=\"Greenland\"> Greenland <\/option>\n                      <option value=\"Grenada\"> Grenada <\/option>\n                      <option value=\"Guadeloupe\"> Guadeloupe <\/option>\n                      <option value=\"Guam\"> Guam <\/option>\n                      <option value=\"Guatemala\"> Guatemala <\/option>\n                      <option value=\"Guernsey\"> Guernsey <\/option>\n                      <option value=\"Guinea\"> Guinea <\/option>\n                      <option value=\"Guinea-Bissau\"> Guinea-Bissau <\/option>\n                      <option value=\"Guyana\"> Guyana <\/option>\n                      <option value=\"Haiti\"> Haiti <\/option>\n                      <option value=\"Honduras\"> Honduras <\/option>\n                      <option value=\"Hong Kong\"> Hong Kong <\/option>\n                      <option value=\"Hungary\"> Hungary <\/option>\n                      <option value=\"Iceland\"> Iceland <\/option>\n                      <option value=\"India\"> India <\/option>\n                      <option value=\"Indonesia\"> Indonesia <\/option>\n                      <option value=\"Iran\"> Iran <\/option>\n                      <option value=\"Iraq\"> Iraq <\/option>\n                      <option value=\"Ireland\"> Ireland <\/option>\n                      <option value=\"Israel\"> Israel <\/option>\n                      <option value=\"Italy\"> Italy <\/option>\n                      <option value=\"Jamaica\"> Jamaica <\/option>\n                      <option value=\"Japan\"> Japan <\/option>\n                      <option value=\"Jersey\"> Jersey <\/option>\n                      <option value=\"Jordan\"> Jordan <\/option>\n                      <option value=\"Kazakhstan\"> Kazakhstan <\/option>\n                      <option value=\"Kenya\"> Kenya <\/option>\n                      <option value=\"Kiribati\"> Kiribati <\/option>\n                      <option value=\"North Korea\"> North Korea <\/option>\n                      <option value=\"South Korea\"> South Korea <\/option>\n                      <option value=\"Kosovo\"> Kosovo <\/option>\n                      <option value=\"Kuwait\"> Kuwait <\/option>\n                      <option value=\"Kyrgyzstan\"> Kyrgyzstan <\/option>\n                      <option value=\"Laos\"> Laos <\/option>\n                      <option value=\"Latvia\"> Latvia <\/option>\n                      <option value=\"Lebanon\"> Lebanon <\/option>\n                      <option value=\"Lesotho\"> Lesotho <\/option>\n                      <option value=\"Liberia\"> Liberia <\/option>\n                      <option value=\"Libya\"> Libya <\/option>\n                      <option value=\"Liechtenstein\"> Liechtenstein <\/option>\n                      <option value=\"Lithuania\"> Lithuania <\/option>\n                      <option value=\"Luxembourg\"> Luxembourg <\/option>\n                      <option value=\"Macau\"> Macau <\/option>\n                      <option value=\"Macedonia\"> Macedonia <\/option>\n                      <option value=\"Madagascar\"> Madagascar <\/option>\n                      <option value=\"Malawi\"> Malawi <\/option>\n                      <option value=\"Malaysia\"> Malaysia <\/option>\n                      <option value=\"Maldives\"> Maldives <\/option>\n                      <option value=\"Mali\"> Mali <\/option>\n                      <option value=\"Malta\"> Malta <\/option>\n                      <option value=\"Marshall Islands\"> Marshall Islands <\/option>\n                      <option value=\"Martinique\"> Martinique <\/option>\n                      <option value=\"Mauritania\"> Mauritania <\/option>\n                      <option value=\"Mauritius\"> Mauritius <\/option>\n                      <option value=\"Mayotte\"> Mayotte <\/option>\n                      <option value=\"Mexico\"> Mexico <\/option>\n                      <option value=\"Micronesia\"> Micronesia <\/option>\n                      <option value=\"Moldova\"> Moldova <\/option>\n                      <option value=\"Monaco\"> Monaco <\/option>\n                      <option value=\"Mongolia\"> Mongolia <\/option>\n                      <option value=\"Montenegro\"> Montenegro <\/option>\n                      <option value=\"Montserrat\"> Montserrat <\/option>\n                      <option value=\"Morocco\"> Morocco <\/option>\n                      <option value=\"Mozambique\"> Mozambique <\/option>\n                      <option value=\"Myanmar\"> Myanmar <\/option>\n                      <option value=\"Nagorno-Karabakh\"> Nagorno-Karabakh <\/option>\n                      <option value=\"Namibia\"> Namibia <\/option>\n                      <option value=\"Nauru\"> Nauru <\/option>\n                      <option value=\"Nepal\"> Nepal <\/option>\n                      <option value=\"Netherlands\"> Netherlands <\/option>\n                      <option value=\"Netherlands Antilles\"> Netherlands Antilles <\/option>\n                      <option value=\"New Caledonia\"> New Caledonia <\/option>\n                      <option value=\"New Zealand\"> New Zealand <\/option>\n                      <option value=\"Nicaragua\"> Nicaragua <\/option>\n                      <option value=\"Niger\"> Niger <\/option>\n                      <option value=\"Nigeria\"> Nigeria <\/option>\n                      <option value=\"Niue\"> Niue <\/option>\n                      <option value=\"Norfolk Island\"> Norfolk Island <\/option>\n                      <option value=\"Turkish Republic of Northern Cyprus\"> Turkish Republic of Northern Cyprus <\/option>\n                      <option value=\"Northern Mariana\"> Northern Mariana <\/option>\n                      <option value=\"Norway\"> Norway <\/option>\n                      <option value=\"Oman\"> Oman <\/option>\n                      <option value=\"Pakistan\"> Pakistan <\/option>\n                      <option value=\"Palau\"> Palau <\/option>\n                      <option value=\"Palestine\"> Palestine <\/option>\n                      <option value=\"Panama\"> Panama <\/option>\n                      <option value=\"Papua New Guinea\"> Papua New Guinea <\/option>\n                      <option value=\"Paraguay\"> Paraguay <\/option>\n                      <option value=\"Peru\"> Peru <\/option>\n                      <option value=\"Philippines\"> Philippines <\/option>\n                      <option value=\"Pitcairn Islands\"> Pitcairn Islands <\/option>\n                      <option value=\"Poland\"> Poland <\/option>\n                      <option value=\"Portugal\"> Portugal <\/option>\n                      <option value=\"Puerto Rico\"> Puerto Rico <\/option>\n                      <option value=\"Qatar\"> Qatar <\/option>\n                      <option value=\"Republic of the Congo\"> Republic of the Congo <\/option>\n                      <option value=\"Romania\"> Romania <\/option>\n                      <option value=\"Russia\"> Russia <\/option>\n                      <option value=\"Rwanda\"> Rwanda <\/option>\n                      <option value=\"Saint Barthelemy\"> Saint Barthelemy <\/option>\n                      <option value=\"Saint Helena\"> Saint Helena <\/option>\n                      <option value=\"Saint Kitts and Nevis\"> Saint Kitts and Nevis <\/option>\n                      <option value=\"Saint Lucia\"> Saint Lucia <\/option>\n                      <option value=\"Saint Martin\"> Saint Martin <\/option>\n                      <option value=\"Saint Pierre and Miquelon\"> Saint Pierre and Miquelon <\/option>\n                      <option value=\"Saint Vincent and the Grenadines\"> Saint Vincent and the Grenadines <\/option>\n                      <option value=\"Samoa\"> Samoa <\/option>\n                      <option value=\"San Marino\"> San Marino <\/option>\n                      <option value=\"Sao Tome and Principe\"> Sao Tome and Principe <\/option>\n                      <option value=\"Saudi Arabia\"> Saudi Arabia <\/option>\n                      <option value=\"Senegal\"> Senegal <\/option>\n                      <option value=\"Serbia\"> Serbia <\/option>\n                      <option value=\"Seychelles\"> Seychelles <\/option>\n                      <option value=\"Sierra Leone\"> Sierra Leone <\/option>\n                      <option value=\"Singapore\"> Singapore <\/option>\n                      <option value=\"Slovakia\"> Slovakia <\/option>\n                      <option value=\"Slovenia\"> Slovenia <\/option>\n                      <option value=\"Solomon Islands\"> Solomon Islands <\/option>\n                      <option value=\"Somalia\"> Somalia <\/option>\n                      <option value=\"Somaliland\"> Somaliland <\/option>\n                      <option value=\"South Africa\"> South Africa <\/option>\n                      <option value=\"South Ossetia\"> South Ossetia <\/option>\n                      <option value=\"South Sudan\"> South Sudan <\/option>\n                      <option value=\"Spain\"> Spain <\/option>\n                      <option value=\"Sri Lanka\"> Sri Lanka <\/option>\n                      <option value=\"Sudan\"> Sudan <\/option>\n                      <option value=\"Suriname\"> Suriname <\/option>\n                      <option value=\"Svalbard\"> Svalbard <\/option>\n                      <option value=\"eSwatini\"> eSwatini <\/option>\n                      <option value=\"Sweden\"> Sweden <\/option>\n                      <option value=\"Switzerland\"> Switzerland <\/option>\n                      <option value=\"Syria\"> Syria <\/option>\n                      <option value=\"Taiwan\"> Taiwan <\/option>\n                      <option value=\"Tajikistan\"> Tajikistan <\/option>\n                      <option value=\"Tanzania\"> Tanzania <\/option>\n                      <option value=\"Thailand\"> Thailand <\/option>\n                      <option value=\"Timor-Leste\"> Timor-Leste <\/option>\n                      <option value=\"Togo\"> Togo <\/option>\n                      <option value=\"Tokelau\"> Tokelau <\/option>\n                      <option value=\"Tonga\"> Tonga <\/option>\n                      <option value=\"Transnistria Pridnestrovie\"> Transnistria Pridnestrovie <\/option>\n                      <option value=\"Trinidad and Tobago\"> Trinidad and Tobago <\/option>\n                      <option value=\"Tristan da Cunha\"> Tristan da Cunha <\/option>\n                      <option value=\"Tunisia\"> Tunisia <\/option>\n                      <option value=\"Turkey\"> Turkey <\/option>\n                      <option value=\"Turkmenistan\"> Turkmenistan <\/option>\n                      <option value=\"Turks and Caicos Islands\"> Turks and Caicos Islands <\/option>\n                      <option value=\"Tuvalu\"> Tuvalu <\/option>\n                      <option value=\"Uganda\"> Uganda <\/option>\n                      <option value=\"Ukraine\"> Ukraine <\/option>\n                      <option value=\"United Arab Emirates\"> United Arab Emirates <\/option>\n                      <option value=\"United Kingdom\"> United Kingdom <\/option>\n                      <option value=\"Uruguay\"> Uruguay <\/option>\n                      <option value=\"Uzbekistan\"> Uzbekistan <\/option>\n                      <option value=\"Vanuatu\"> Vanuatu <\/option>\n                      <option value=\"Vatican City\"> Vatican City <\/option>\n                      <option value=\"Venezuela\"> Venezuela <\/option>\n                      <option value=\"Vietnam\"> Vietnam <\/option>\n                      <option value=\"British Virgin Islands\"> British Virgin Islands <\/option>\n                      <option value=\"Isle of Man\"> Isle of Man <\/option>\n                      <option value=\"US Virgin Islands\"> US Virgin Islands <\/option>\n                      <option value=\"Wallis and Futuna\"> Wallis and Futuna <\/option>\n                      <option value=\"Western Sahara\"> Western Sahara <\/option>\n                      <option value=\"Yemen\"> Yemen <\/option>\n                      <option value=\"Zambia\"> Zambia <\/option>\n                      <option value=\"Zimbabwe\"> Zimbabwe <\/option>\n                      <option value=\"other\"> Other <\/option>\n                    <\/select>\n                    <label class=\"form-sub-label\" for=\"input_9_country\" id=\"sublabel_9_country\" style=\"min-height:13px\"> Country <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n            <\/tbody>\n          <\/table>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1\" data-type=\"control_phone\" id=\"id_10\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_10\" for=\"input_10_area\"> Landline Phone Number <\/label>\n        <div id=\"cid_10\" class=\"form-input-wide\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"tel\" id=\"input_10_area\" name=\"q10_landlinePhone[area]\" class=\"form-textbox\" size=\"6\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_10 sublabel_10_area\" \/>\n              <span class=\"phone-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_10_area\" id=\"sublabel_10_area\" style=\"min-height:13px\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"tel\" id=\"input_10_phone\" name=\"q10_landlinePhone[phone]\" class=\"form-textbox\" size=\"12\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_10 sublabel_10_phone\" \/>\n              <label class=\"form-sub-label\" for=\"input_10_phone\" id=\"sublabel_10_phone\" style=\"min-height:13px\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2 jf-required\" data-type=\"control_phone\" id=\"id_22\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_22\" for=\"input_22_area\">\n          Mobile Phone Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_22\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"tel\" id=\"input_22_area\" name=\"q22_mobilePhone[area]\" class=\"form-textbox validate[required]\" size=\"6\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_22 sublabel_22_area\" required=\"\" \/>\n              <span class=\"phone-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_22_area\" id=\"sublabel_22_area\" style=\"min-height:13px\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"tel\" id=\"input_22_phone\" name=\"q22_mobilePhone[phone]\" class=\"form-textbox validate[required]\" size=\"12\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_22 sublabel_22_phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_22_phone\" id=\"sublabel_22_phone\" style=\"min-height:13px\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-3\" data-type=\"control_email\" id=\"id_26\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_26\" for=\"input_26\"> Email address <\/label>\n        <div id=\"cid_26\" class=\"form-input-wide\">\n          <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n            <input type=\"email\" id=\"input_26\" name=\"q26_emailAddress26\" class=\"form-textbox validate[Email]\" size=\"30\" value=\"\" data-component=\"email\" aria-labelledby=\"label_26 sublabel_input_26\" \/>\n            <label class=\"form-sub-label\" for=\"input_26\" id=\"sublabel_input_26\" style=\"min-height:13px\"> example@example.com <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_27\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_27\" for=\"input_27\">\n          Is it a self-referral?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_27\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_27\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_27_0\" name=\"q27_isIt27\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_27_0\" for=\"input_27_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_27_1\" name=\"q27_isIt27\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_27_1\" for=\"input_27_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 jf-required form-field-hidden\" style=\"display:none;\" data-type=\"control_fullname\" id=\"id_11\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_11\" for=\"prefix_11\">\n          Referrers Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_11\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"prefix_11\" name=\"q11_name11[prefix]\" class=\"form-textbox\" size=\"4\" value=\"\" data-component=\"prefix\" aria-labelledby=\"label_11 sublabel_11_prefix\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"prefix_11\" id=\"sublabel_11_prefix\" style=\"min-height:13px\"> Prefix <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"first_11\" name=\"q11_name11[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_11 sublabel_11_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_11\" id=\"sublabel_11_first\" style=\"min-height:13px\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"last_11\" name=\"q11_name11[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_11 sublabel_11_last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_11\" id=\"sublabel_11_last\" style=\"min-height:13px\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2\" data-type=\"control_datetime\" id=\"id_12\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_12\" for=\"lite_mode_12\"> Date of referral <\/label>\n        <div id=\"cid_12\" class=\"form-input-wide\">\n          <div data-wrapper-react=\"true\">\n            <div style=\"display:none\">\n              <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[limitDate]\" id=\"day_12\" name=\"q12_dateOf[day]\" size=\"2\" data-maxlength=\"2\" value=\"\" aria-labelledby=\"label_12 sublabel_12_day\" \/>\n                <span class=\"date-separate\" aria-hidden=\"true\">\n                  \u00a0-\n                <\/span>\n                <label class=\"form-sub-label\" for=\"day_12\" id=\"sublabel_12_day\" style=\"min-height:13px\"> Day <\/label>\n              <\/span>\n              <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[limitDate]\" id=\"month_12\" name=\"q12_dateOf[month]\" size=\"2\" data-maxlength=\"2\" value=\"\" aria-labelledby=\"label_12 sublabel_12_month\" \/>\n                <span class=\"date-separate\" aria-hidden=\"true\">\n                  \u00a0-\n                <\/span>\n                <label class=\"form-sub-label\" for=\"month_12\" id=\"sublabel_12_month\" style=\"min-height:13px\"> Month <\/label>\n              <\/span>\n              <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[limitDate]\" id=\"year_12\" name=\"q12_dateOf[year]\" size=\"4\" data-maxlength=\"4\" value=\"\" aria-labelledby=\"label_12 sublabel_12_year\" \/>\n                <label class=\"form-sub-label\" for=\"year_12\" id=\"sublabel_12_year\" style=\"min-height:13px\"> Year <\/label>\n              <\/span>\n            <\/div>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" class=\"form-textbox validate[limitDate, validateLiteDate]\" id=\"lite_mode_12\" size=\"12\" data-maxlength=\"12\" data-age=\"\" value=\"\" data-format=\"ddmmyyyy\" data-seperator=\"-\" placeholder=\"dd-mm-yyyy\" aria-labelledby=\"label_12 sublabel_12_litemode\" \/>\n              <img alt=\"Pick a Date\" id=\"input_12_pick\" src=\"https:\/\/alt.jotfor.ms\/images\/calendar.png\" style=\"vertical-align:middle;margin-left:5px\" data-component=\"datetime\" aria-hidden=\"true\" \/>\n              <label class=\"form-sub-label\" for=\"lite_mode_12\" id=\"sublabel_12_litemode\" style=\"min-height:13px\"> Date <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <label class=\"form-sub-label\" for=\"input_12_pick\" style=\"border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap\"> Date Picker Icon <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_address\" id=\"id_13\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_13\" for=\"input_13_addr_line1\"> Referrers postal address <\/label>\n        <div id=\"cid_13\" class=\"form-input-wide\">\n          <table summary=\"\" class=\"form-address-table\">\n            <tbody>\n              <tr>\n                <td colSpan=\"2\">\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_13_addr_line1\" name=\"q13_referrersPostal[addr_line1]\" class=\"form-textbox form-address-line\" autoComplete=\"address-line1\" value=\"\" data-component=\"address_line_1\" aria-labelledby=\"label_13 sublabel_13_addr_line1\" \/>\n                    <label class=\"form-sub-label\" for=\"input_13_addr_line1\" id=\"sublabel_13_addr_line1\" style=\"min-height:13px\"> Street Address <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td colSpan=\"2\">\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_13_addr_line2\" name=\"q13_referrersPostal[addr_line2]\" class=\"form-textbox form-address-line\" autoComplete=\"address-line2\" size=\"46\" value=\"\" data-component=\"address_line_2\" aria-labelledby=\"label_13 sublabel_13_addr_line2\" \/>\n                    <label class=\"form-sub-label\" for=\"input_13_addr_line2\" id=\"sublabel_13_addr_line2\" style=\"min-height:13px\"> Street Address Line 2 <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td>\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_13_city\" name=\"q13_referrersPostal[city]\" class=\"form-textbox form-address-city\" autoComplete=\"address-level2\" size=\"21\" value=\"\" data-component=\"city\" aria-labelledby=\"label_13 sublabel_13_city\" \/>\n                    <label class=\"form-sub-label\" for=\"input_13_city\" id=\"sublabel_13_city\" style=\"min-height:13px\"> City\/Town <\/label>\n                  <\/span>\n                <\/td>\n                <td>\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_13_state\" name=\"q13_referrersPostal[state]\" class=\"form-textbox form-address-state\" autoComplete=\"address-level1\" size=\"22\" value=\"\" data-component=\"state\" aria-labelledby=\"label_13 sublabel_13_state\" \/>\n                    <label class=\"form-sub-label\" for=\"input_13_state\" id=\"sublabel_13_state\" style=\"min-height:13px\"> Region <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td>\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_13_postal\" name=\"q13_referrersPostal[postal]\" class=\"form-textbox form-address-postal\" autoComplete=\"postal-code\" size=\"10\" value=\"\" data-component=\"zip\" aria-labelledby=\"label_13 sublabel_13_postal\" \/>\n                    <label class=\"form-sub-label\" for=\"input_13_postal\" id=\"sublabel_13_postal\" style=\"min-height:13px\"> Post Code <\/label>\n                  <\/span>\n                <\/td>\n                <td style=\"display:none\">\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <select class=\"form-dropdown form-address-country noTranslate\" name=\"q13_referrersPostal[country]\" id=\"input_13_country\" data-component=\"country\" aria-labelledby=\"label_13 sublabel_13_country\" autoComplete=\"new-password\">\n                      <option value=\"\"> Please Select <\/option>\n                      <option value=\"United States\"> United States <\/option>\n                      <option value=\"Afghanistan\"> Afghanistan <\/option>\n                      <option value=\"Albania\"> Albania <\/option>\n                      <option value=\"Algeria\"> Algeria <\/option>\n                      <option value=\"American Samoa\"> American Samoa <\/option>\n                      <option value=\"Andorra\"> Andorra <\/option>\n                      <option value=\"Angola\"> Angola <\/option>\n                      <option value=\"Anguilla\"> Anguilla <\/option>\n                      <option value=\"Antigua and Barbuda\"> Antigua and Barbuda <\/option>\n                      <option value=\"Argentina\"> Argentina <\/option>\n                      <option value=\"Armenia\"> Armenia <\/option>\n                      <option value=\"Aruba\"> Aruba <\/option>\n                      <option value=\"Australia\"> Australia <\/option>\n                      <option value=\"Austria\"> Austria <\/option>\n                      <option value=\"Azerbaijan\"> Azerbaijan <\/option>\n                      <option value=\"The Bahamas\"> The Bahamas <\/option>\n                      <option value=\"Bahrain\"> Bahrain <\/option>\n                      <option value=\"Bangladesh\"> Bangladesh <\/option>\n                      <option value=\"Barbados\"> Barbados <\/option>\n                      <option value=\"Belarus\"> Belarus <\/option>\n                      <option value=\"Belgium\"> Belgium <\/option>\n                      <option value=\"Belize\"> Belize <\/option>\n                      <option value=\"Benin\"> Benin <\/option>\n                      <option value=\"Bermuda\"> Bermuda <\/option>\n                      <option value=\"Bhutan\"> Bhutan <\/option>\n                      <option value=\"Bolivia\"> Bolivia <\/option>\n                      <option value=\"Bosnia and Herzegovina\"> Bosnia and Herzegovina <\/option>\n                      <option value=\"Botswana\"> Botswana <\/option>\n                      <option value=\"Brazil\"> Brazil <\/option>\n                      <option value=\"Brunei\"> Brunei <\/option>\n                      <option value=\"Bulgaria\"> Bulgaria <\/option>\n                      <option value=\"Burkina Faso\"> Burkina Faso <\/option>\n                      <option value=\"Burundi\"> Burundi <\/option>\n                      <option value=\"Cambodia\"> Cambodia <\/option>\n                      <option value=\"Cameroon\"> Cameroon <\/option>\n                      <option value=\"Canada\"> Canada <\/option>\n                      <option value=\"Cape Verde\"> Cape Verde <\/option>\n                      <option value=\"Cayman Islands\"> Cayman Islands <\/option>\n                      <option value=\"Central African Republic\"> Central African Republic <\/option>\n                      <option value=\"Chad\"> Chad <\/option>\n                      <option value=\"Chile\"> Chile <\/option>\n                      <option value=\"China\"> China <\/option>\n                      <option value=\"Christmas Island\"> Christmas Island <\/option>\n                      <option value=\"Cocos (Keeling) Islands\"> Cocos (Keeling) Islands <\/option>\n                      <option value=\"Colombia\"> Colombia <\/option>\n                      <option value=\"Comoros\"> Comoros <\/option>\n                      <option value=\"Congo\"> Congo <\/option>\n                      <option value=\"Cook Islands\"> Cook Islands <\/option>\n                      <option value=\"Costa Rica\"> Costa Rica <\/option>\n                      <option value=\"Cote d&#x27;Ivoire\"> Cote d&#x27;Ivoire <\/option>\n                      <option value=\"Croatia\"> Croatia <\/option>\n                      <option value=\"Cuba\"> Cuba <\/option>\n                      <option value=\"Cyprus\"> Cyprus <\/option>\n                      <option value=\"Czech Republic\"> Czech Republic <\/option>\n                      <option value=\"Democratic Republic of the Congo\"> Democratic Republic of the Congo <\/option>\n                      <option value=\"Denmark\"> Denmark <\/option>\n                      <option value=\"Djibouti\"> Djibouti <\/option>\n                      <option value=\"Dominica\"> Dominica <\/option>\n                      <option value=\"Dominican Republic\"> Dominican Republic <\/option>\n                      <option value=\"Ecuador\"> Ecuador <\/option>\n                      <option value=\"Egypt\"> Egypt <\/option>\n                      <option value=\"El Salvador\"> El Salvador <\/option>\n                      <option value=\"Equatorial Guinea\"> Equatorial Guinea <\/option>\n                      <option value=\"Eritrea\"> Eritrea <\/option>\n                      <option value=\"Estonia\"> Estonia <\/option>\n                      <option value=\"Ethiopia\"> Ethiopia <\/option>\n                      <option value=\"Falkland Islands\"> Falkland Islands <\/option>\n                      <option value=\"Faroe Islands\"> Faroe Islands <\/option>\n                      <option value=\"Fiji\"> Fiji <\/option>\n                      <option value=\"Finland\"> Finland <\/option>\n                      <option value=\"France\"> France <\/option>\n                      <option value=\"French Polynesia\"> French Polynesia <\/option>\n                      <option value=\"Gabon\"> Gabon <\/option>\n                      <option value=\"The Gambia\"> The Gambia <\/option>\n                      <option value=\"Georgia\"> Georgia <\/option>\n                      <option value=\"Germany\"> Germany <\/option>\n                      <option value=\"Ghana\"> Ghana <\/option>\n                      <option value=\"Gibraltar\"> Gibraltar <\/option>\n                      <option value=\"Greece\"> Greece <\/option>\n                      <option value=\"Greenland\"> Greenland <\/option>\n                      <option value=\"Grenada\"> Grenada <\/option>\n                      <option value=\"Guadeloupe\"> Guadeloupe <\/option>\n                      <option value=\"Guam\"> Guam <\/option>\n                      <option value=\"Guatemala\"> Guatemala <\/option>\n                      <option value=\"Guernsey\"> Guernsey <\/option>\n                      <option value=\"Guinea\"> Guinea <\/option>\n                      <option value=\"Guinea-Bissau\"> Guinea-Bissau <\/option>\n                      <option value=\"Guyana\"> Guyana <\/option>\n                      <option value=\"Haiti\"> Haiti <\/option>\n                      <option value=\"Honduras\"> Honduras <\/option>\n                      <option value=\"Hong Kong\"> Hong Kong <\/option>\n                      <option value=\"Hungary\"> Hungary <\/option>\n                      <option value=\"Iceland\"> Iceland <\/option>\n                      <option value=\"India\"> India <\/option>\n                      <option value=\"Indonesia\"> Indonesia <\/option>\n                      <option value=\"Iran\"> Iran <\/option>\n                      <option value=\"Iraq\"> Iraq <\/option>\n                      <option value=\"Ireland\"> Ireland <\/option>\n                      <option value=\"Israel\"> Israel <\/option>\n                      <option value=\"Italy\"> Italy <\/option>\n                      <option value=\"Jamaica\"> Jamaica <\/option>\n                      <option value=\"Japan\"> Japan <\/option>\n                      <option value=\"Jersey\"> Jersey <\/option>\n                      <option value=\"Jordan\"> Jordan <\/option>\n                      <option value=\"Kazakhstan\"> Kazakhstan <\/option>\n                      <option value=\"Kenya\"> Kenya <\/option>\n                      <option value=\"Kiribati\"> Kiribati <\/option>\n                      <option value=\"North Korea\"> North Korea <\/option>\n                      <option value=\"South Korea\"> South Korea <\/option>\n                      <option value=\"Kosovo\"> Kosovo <\/option>\n                      <option value=\"Kuwait\"> Kuwait <\/option>\n                      <option value=\"Kyrgyzstan\"> Kyrgyzstan <\/option>\n                      <option value=\"Laos\"> Laos <\/option>\n                      <option value=\"Latvia\"> Latvia <\/option>\n                      <option value=\"Lebanon\"> Lebanon <\/option>\n                      <option value=\"Lesotho\"> Lesotho <\/option>\n                      <option value=\"Liberia\"> Liberia <\/option>\n                      <option value=\"Libya\"> Libya <\/option>\n                      <option value=\"Liechtenstein\"> Liechtenstein <\/option>\n                      <option value=\"Lithuania\"> Lithuania <\/option>\n                      <option value=\"Luxembourg\"> Luxembourg <\/option>\n                      <option value=\"Macau\"> Macau <\/option>\n                      <option value=\"Macedonia\"> Macedonia <\/option>\n                      <option value=\"Madagascar\"> Madagascar <\/option>\n                      <option value=\"Malawi\"> Malawi <\/option>\n                      <option value=\"Malaysia\"> Malaysia <\/option>\n                      <option value=\"Maldives\"> Maldives <\/option>\n                      <option value=\"Mali\"> Mali <\/option>\n                      <option value=\"Malta\"> Malta <\/option>\n                      <option value=\"Marshall Islands\"> Marshall Islands <\/option>\n                      <option value=\"Martinique\"> Martinique <\/option>\n                      <option value=\"Mauritania\"> Mauritania <\/option>\n                      <option value=\"Mauritius\"> Mauritius <\/option>\n                      <option value=\"Mayotte\"> Mayotte <\/option>\n                      <option value=\"Mexico\"> Mexico <\/option>\n                      <option value=\"Micronesia\"> Micronesia <\/option>\n                      <option value=\"Moldova\"> Moldova <\/option>\n                      <option value=\"Monaco\"> Monaco <\/option>\n                      <option value=\"Mongolia\"> Mongolia <\/option>\n                      <option value=\"Montenegro\"> Montenegro <\/option>\n                      <option value=\"Montserrat\"> Montserrat <\/option>\n                      <option value=\"Morocco\"> Morocco <\/option>\n                      <option value=\"Mozambique\"> Mozambique <\/option>\n                      <option value=\"Myanmar\"> Myanmar <\/option>\n                      <option value=\"Nagorno-Karabakh\"> Nagorno-Karabakh <\/option>\n                      <option value=\"Namibia\"> Namibia <\/option>\n                      <option value=\"Nauru\"> Nauru <\/option>\n                      <option value=\"Nepal\"> Nepal <\/option>\n                      <option value=\"Netherlands\"> Netherlands <\/option>\n                      <option value=\"Netherlands Antilles\"> Netherlands Antilles <\/option>\n                      <option value=\"New Caledonia\"> New Caledonia <\/option>\n                      <option value=\"New Zealand\"> New Zealand <\/option>\n                      <option value=\"Nicaragua\"> Nicaragua <\/option>\n                      <option value=\"Niger\"> Niger <\/option>\n                      <option value=\"Nigeria\"> Nigeria <\/option>\n                      <option value=\"Niue\"> Niue <\/option>\n                      <option value=\"Norfolk Island\"> Norfolk Island <\/option>\n                      <option value=\"Turkish Republic of Northern Cyprus\"> Turkish Republic of Northern Cyprus <\/option>\n                      <option value=\"Northern Mariana\"> Northern Mariana <\/option>\n                      <option value=\"Norway\"> Norway <\/option>\n                      <option value=\"Oman\"> Oman <\/option>\n                      <option value=\"Pakistan\"> Pakistan <\/option>\n                      <option value=\"Palau\"> Palau <\/option>\n                      <option value=\"Palestine\"> Palestine <\/option>\n                      <option value=\"Panama\"> Panama <\/option>\n                      <option value=\"Papua New Guinea\"> Papua New Guinea <\/option>\n                      <option value=\"Paraguay\"> Paraguay <\/option>\n                      <option value=\"Peru\"> Peru <\/option>\n                      <option value=\"Philippines\"> Philippines <\/option>\n                      <option value=\"Pitcairn Islands\"> Pitcairn Islands <\/option>\n                      <option value=\"Poland\"> Poland <\/option>\n                      <option value=\"Portugal\"> Portugal <\/option>\n                      <option value=\"Puerto Rico\"> Puerto Rico <\/option>\n                      <option value=\"Qatar\"> Qatar <\/option>\n                      <option value=\"Republic of the Congo\"> Republic of the Congo <\/option>\n                      <option value=\"Romania\"> Romania <\/option>\n                      <option value=\"Russia\"> Russia <\/option>\n                      <option value=\"Rwanda\"> Rwanda <\/option>\n                      <option value=\"Saint Barthelemy\"> Saint Barthelemy <\/option>\n                      <option value=\"Saint Helena\"> Saint Helena <\/option>\n                      <option value=\"Saint Kitts and Nevis\"> Saint Kitts and Nevis <\/option>\n                      <option value=\"Saint Lucia\"> Saint Lucia <\/option>\n                      <option value=\"Saint Martin\"> Saint Martin <\/option>\n                      <option value=\"Saint Pierre and Miquelon\"> Saint Pierre and Miquelon <\/option>\n                      <option value=\"Saint Vincent and the Grenadines\"> Saint Vincent and the Grenadines <\/option>\n                      <option value=\"Samoa\"> Samoa <\/option>\n                      <option value=\"San Marino\"> San Marino <\/option>\n                      <option value=\"Sao Tome and Principe\"> Sao Tome and Principe <\/option>\n                      <option value=\"Saudi Arabia\"> Saudi Arabia <\/option>\n                      <option value=\"Senegal\"> Senegal <\/option>\n                      <option value=\"Serbia\"> Serbia <\/option>\n                      <option value=\"Seychelles\"> Seychelles <\/option>\n                      <option value=\"Sierra Leone\"> Sierra Leone <\/option>\n                      <option value=\"Singapore\"> Singapore <\/option>\n                      <option value=\"Slovakia\"> Slovakia <\/option>\n                      <option value=\"Slovenia\"> Slovenia <\/option>\n                      <option value=\"Solomon Islands\"> Solomon Islands <\/option>\n                      <option value=\"Somalia\"> Somalia <\/option>\n                      <option value=\"Somaliland\"> Somaliland <\/option>\n                      <option value=\"South Africa\"> South Africa <\/option>\n                      <option value=\"South Ossetia\"> South Ossetia <\/option>\n                      <option value=\"South Sudan\"> South Sudan <\/option>\n                      <option value=\"Spain\"> Spain <\/option>\n                      <option value=\"Sri Lanka\"> Sri Lanka <\/option>\n                      <option value=\"Sudan\"> Sudan <\/option>\n                      <option value=\"Suriname\"> Suriname <\/option>\n                      <option value=\"Svalbard\"> Svalbard <\/option>\n                      <option value=\"eSwatini\"> eSwatini <\/option>\n                      <option value=\"Sweden\"> Sweden <\/option>\n                      <option value=\"Switzerland\"> Switzerland <\/option>\n                      <option value=\"Syria\"> Syria <\/option>\n                      <option value=\"Taiwan\"> Taiwan <\/option>\n                      <option value=\"Tajikistan\"> Tajikistan <\/option>\n                      <option value=\"Tanzania\"> Tanzania <\/option>\n                      <option value=\"Thailand\"> Thailand <\/option>\n                      <option value=\"Timor-Leste\"> Timor-Leste <\/option>\n                      <option value=\"Togo\"> Togo <\/option>\n                      <option value=\"Tokelau\"> Tokelau <\/option>\n                      <option value=\"Tonga\"> Tonga <\/option>\n                      <option value=\"Transnistria Pridnestrovie\"> Transnistria Pridnestrovie <\/option>\n                      <option value=\"Trinidad and Tobago\"> Trinidad and Tobago <\/option>\n                      <option value=\"Tristan da Cunha\"> Tristan da Cunha <\/option>\n                      <option value=\"Tunisia\"> Tunisia <\/option>\n                      <option value=\"Turkey\"> Turkey <\/option>\n                      <option value=\"Turkmenistan\"> Turkmenistan <\/option>\n                      <option value=\"Turks and Caicos Islands\"> Turks and Caicos Islands <\/option>\n                      <option value=\"Tuvalu\"> Tuvalu <\/option>\n                      <option value=\"Uganda\"> Uganda <\/option>\n                      <option value=\"Ukraine\"> Ukraine <\/option>\n                      <option value=\"United Arab Emirates\"> United Arab Emirates <\/option>\n                      <option value=\"United Kingdom\"> United Kingdom <\/option>\n                      <option value=\"Uruguay\"> Uruguay <\/option>\n                      <option value=\"Uzbekistan\"> Uzbekistan <\/option>\n                      <option value=\"Vanuatu\"> Vanuatu <\/option>\n                      <option value=\"Vatican City\"> Vatican City <\/option>\n                      <option value=\"Venezuela\"> Venezuela <\/option>\n                      <option value=\"Vietnam\"> Vietnam <\/option>\n                      <option value=\"British Virgin Islands\"> British Virgin Islands <\/option>\n                      <option value=\"Isle of Man\"> Isle of Man <\/option>\n                      <option value=\"US Virgin Islands\"> US Virgin Islands <\/option>\n                      <option value=\"Wallis and Futuna\"> Wallis and Futuna <\/option>\n                      <option value=\"Western Sahara\"> Western Sahara <\/option>\n                      <option value=\"Yemen\"> Yemen <\/option>\n                      <option value=\"Zambia\"> Zambia <\/option>\n                      <option value=\"Zimbabwe\"> Zimbabwe <\/option>\n                      <option value=\"other\"> Other <\/option>\n                    <\/select>\n                    <label class=\"form-sub-label\" for=\"input_13_country\" id=\"sublabel_13_country\" style=\"min-height:13px\"> Country <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n            <\/tbody>\n          <\/table>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 jf-required form-field-hidden\" style=\"display:none;\" data-type=\"control_phone\" id=\"id_14\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_14\" for=\"input_14_area\">\n          Referrers phone number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_14\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"tel\" id=\"input_14_area\" name=\"q14_referrersPhone14[area]\" class=\"form-textbox validate[required]\" size=\"6\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_14 sublabel_14_area\" required=\"\" \/>\n              <span class=\"phone-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_14_area\" id=\"sublabel_14_area\" style=\"min-height:13px\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"tel\" id=\"input_14_phone\" name=\"q14_referrersPhone14[phone]\" class=\"form-textbox validate[required]\" size=\"12\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_14 sublabel_14_phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_14_phone\" id=\"sublabel_14_phone\" style=\"min-height:13px\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2 jf-required form-field-hidden\" style=\"display:none;\" data-type=\"control_email\" id=\"id_15\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_15\" for=\"input_15\">\n          Referrers email address\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_15\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n            <input type=\"email\" id=\"input_15\" name=\"q15_referrersEmail\" class=\"form-textbox validate[required, Email]\" size=\"30\" value=\"\" data-component=\"email\" aria-labelledby=\"label_15 sublabel_input_15\" required=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_15\" id=\"sublabel_input_15\" style=\"min-height:13px\"> example@example.com <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_fullname\" id=\"id_16\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_16\" for=\"first_16\"> GP and Surgery name <\/label>\n        <div id=\"cid_16\" class=\"form-input-wide\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"first_16\" name=\"q16_gpAnd[first]\" class=\"form-textbox\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_16 sublabel_16_first\" \/>\n              <label class=\"form-sub-label\" for=\"first_16\" id=\"sublabel_16_first\" style=\"min-height:13px\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"last_16\" name=\"q16_gpAnd[last]\" class=\"form-textbox\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_16 sublabel_16_last\" \/>\n              <label class=\"form-sub-label\" for=\"last_16\" id=\"sublabel_16_last\" style=\"min-height:13px\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_address\" id=\"id_17\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_17\" for=\"input_17_addr_line1\"> GP and Surgery Address <\/label>\n        <div id=\"cid_17\" class=\"form-input-wide\">\n          <table summary=\"\" class=\"form-address-table\">\n            <tbody>\n              <tr>\n                <td colSpan=\"2\">\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_17_addr_line1\" name=\"q17_gpAnd17[addr_line1]\" class=\"form-textbox form-address-line\" autoComplete=\"address-line1\" value=\"\" data-component=\"address_line_1\" aria-labelledby=\"label_17 sublabel_17_addr_line1\" \/>\n                    <label class=\"form-sub-label\" for=\"input_17_addr_line1\" id=\"sublabel_17_addr_line1\" style=\"min-height:13px\"> Street Address <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td colSpan=\"2\">\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_17_addr_line2\" name=\"q17_gpAnd17[addr_line2]\" class=\"form-textbox form-address-line\" autoComplete=\"address-line2\" size=\"46\" value=\"\" data-component=\"address_line_2\" aria-labelledby=\"label_17 sublabel_17_addr_line2\" \/>\n                    <label class=\"form-sub-label\" for=\"input_17_addr_line2\" id=\"sublabel_17_addr_line2\" style=\"min-height:13px\"> Street Address Line 2 <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td>\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_17_city\" name=\"q17_gpAnd17[city]\" class=\"form-textbox form-address-city\" autoComplete=\"address-level2\" size=\"21\" value=\"\" data-component=\"city\" aria-labelledby=\"label_17 sublabel_17_city\" \/>\n                    <label class=\"form-sub-label\" for=\"input_17_city\" id=\"sublabel_17_city\" style=\"min-height:13px\"> City <\/label>\n                  <\/span>\n                <\/td>\n                <td>\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_17_state\" name=\"q17_gpAnd17[state]\" class=\"form-textbox form-address-state\" autoComplete=\"address-level1\" size=\"22\" value=\"\" data-component=\"state\" aria-labelledby=\"label_17 sublabel_17_state\" \/>\n                    <label class=\"form-sub-label\" for=\"input_17_state\" id=\"sublabel_17_state\" style=\"min-height:13px\"> State \/ Province <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td>\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_17_postal\" name=\"q17_gpAnd17[postal]\" class=\"form-textbox form-address-postal\" autoComplete=\"postal-code\" size=\"10\" value=\"\" data-component=\"zip\" aria-labelledby=\"label_17 sublabel_17_postal\" \/>\n                    <label class=\"form-sub-label\" for=\"input_17_postal\" id=\"sublabel_17_postal\" style=\"min-height:13px\"> Postal \/ Zip Code <\/label>\n                  <\/span>\n                <\/td>\n                <td style=\"display:none\">\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <select class=\"form-dropdown form-address-country noTranslate\" name=\"q17_gpAnd17[country]\" id=\"input_17_country\" data-component=\"country\" aria-labelledby=\"label_17 sublabel_17_country\" autoComplete=\"new-password\">\n                      <option value=\"\"> Please Select <\/option>\n                      <option value=\"United States\"> United States <\/option>\n                      <option value=\"Afghanistan\"> Afghanistan <\/option>\n                      <option value=\"Albania\"> Albania <\/option>\n                      <option value=\"Algeria\"> Algeria <\/option>\n                      <option value=\"American Samoa\"> American Samoa <\/option>\n                      <option value=\"Andorra\"> Andorra <\/option>\n                      <option value=\"Angola\"> Angola <\/option>\n                      <option value=\"Anguilla\"> Anguilla <\/option>\n                      <option value=\"Antigua and Barbuda\"> Antigua and Barbuda <\/option>\n                      <option value=\"Argentina\"> Argentina <\/option>\n                      <option value=\"Armenia\"> Armenia <\/option>\n                      <option value=\"Aruba\"> Aruba <\/option>\n                      <option value=\"Australia\"> Australia <\/option>\n                      <option value=\"Austria\"> Austria <\/option>\n                      <option value=\"Azerbaijan\"> Azerbaijan <\/option>\n                      <option value=\"The Bahamas\"> The Bahamas <\/option>\n                      <option value=\"Bahrain\"> Bahrain <\/option>\n                      <option value=\"Bangladesh\"> Bangladesh <\/option>\n                      <option value=\"Barbados\"> Barbados <\/option>\n                      <option value=\"Belarus\"> Belarus <\/option>\n                      <option value=\"Belgium\"> Belgium <\/option>\n                      <option value=\"Belize\"> Belize <\/option>\n                      <option value=\"Benin\"> Benin <\/option>\n                      <option value=\"Bermuda\"> Bermuda <\/option>\n                      <option value=\"Bhutan\"> Bhutan <\/option>\n                      <option value=\"Bolivia\"> Bolivia <\/option>\n                      <option value=\"Bosnia and Herzegovina\"> Bosnia and Herzegovina <\/option>\n                      <option value=\"Botswana\"> Botswana <\/option>\n                      <option value=\"Brazil\"> Brazil <\/option>\n                      <option value=\"Brunei\"> Brunei <\/option>\n                      <option value=\"Bulgaria\"> Bulgaria <\/option>\n                      <option value=\"Burkina Faso\"> Burkina Faso <\/option>\n                      <option value=\"Burundi\"> Burundi <\/option>\n                      <option value=\"Cambodia\"> Cambodia <\/option>\n                      <option value=\"Cameroon\"> Cameroon <\/option>\n                      <option value=\"Canada\"> Canada <\/option>\n                      <option value=\"Cape Verde\"> Cape Verde <\/option>\n                      <option value=\"Cayman Islands\"> Cayman Islands <\/option>\n                      <option value=\"Central African Republic\"> Central African Republic <\/option>\n                      <option value=\"Chad\"> Chad <\/option>\n                      <option value=\"Chile\"> Chile <\/option>\n                      <option value=\"China\"> China <\/option>\n                      <option value=\"Christmas Island\"> Christmas Island <\/option>\n                      <option value=\"Cocos (Keeling) Islands\"> Cocos (Keeling) Islands <\/option>\n                      <option value=\"Colombia\"> Colombia <\/option>\n                      <option value=\"Comoros\"> Comoros <\/option>\n                      <option value=\"Congo\"> Congo <\/option>\n                      <option value=\"Cook Islands\"> Cook Islands <\/option>\n                      <option value=\"Costa Rica\"> Costa Rica <\/option>\n                      <option value=\"Cote d&#x27;Ivoire\"> Cote d&#x27;Ivoire <\/option>\n                      <option value=\"Croatia\"> Croatia <\/option>\n                      <option value=\"Cuba\"> Cuba <\/option>\n                      <option value=\"Cyprus\"> Cyprus <\/option>\n                      <option value=\"Czech Republic\"> Czech Republic <\/option>\n                      <option value=\"Democratic Republic of the Congo\"> Democratic Republic of the Congo <\/option>\n                      <option value=\"Denmark\"> Denmark <\/option>\n                      <option value=\"Djibouti\"> Djibouti <\/option>\n                      <option value=\"Dominica\"> Dominica <\/option>\n                      <option value=\"Dominican Republic\"> Dominican Republic <\/option>\n                      <option value=\"Ecuador\"> Ecuador <\/option>\n                      <option value=\"Egypt\"> Egypt <\/option>\n                      <option value=\"El Salvador\"> El Salvador <\/option>\n                      <option value=\"Equatorial Guinea\"> Equatorial Guinea <\/option>\n                      <option value=\"Eritrea\"> Eritrea <\/option>\n                      <option value=\"Estonia\"> Estonia <\/option>\n                      <option value=\"Ethiopia\"> Ethiopia <\/option>\n                      <option value=\"Falkland Islands\"> Falkland Islands <\/option>\n                      <option value=\"Faroe Islands\"> Faroe Islands <\/option>\n                      <option value=\"Fiji\"> Fiji <\/option>\n                      <option value=\"Finland\"> Finland <\/option>\n                      <option value=\"France\"> France <\/option>\n                      <option value=\"French Polynesia\"> French Polynesia <\/option>\n                      <option value=\"Gabon\"> Gabon <\/option>\n                      <option value=\"The Gambia\"> The Gambia <\/option>\n                      <option value=\"Georgia\"> Georgia <\/option>\n                      <option value=\"Germany\"> Germany <\/option>\n                      <option value=\"Ghana\"> Ghana <\/option>\n                      <option value=\"Gibraltar\"> Gibraltar <\/option>\n                      <option value=\"Greece\"> Greece <\/option>\n                      <option value=\"Greenland\"> Greenland <\/option>\n                      <option value=\"Grenada\"> Grenada <\/option>\n                      <option value=\"Guadeloupe\"> Guadeloupe <\/option>\n                      <option value=\"Guam\"> Guam <\/option>\n                      <option value=\"Guatemala\"> Guatemala <\/option>\n                      <option value=\"Guernsey\"> Guernsey <\/option>\n                      <option value=\"Guinea\"> Guinea <\/option>\n                      <option value=\"Guinea-Bissau\"> Guinea-Bissau <\/option>\n                      <option value=\"Guyana\"> Guyana <\/option>\n                      <option value=\"Haiti\"> Haiti <\/option>\n                      <option value=\"Honduras\"> Honduras <\/option>\n                      <option value=\"Hong Kong\"> Hong Kong <\/option>\n                      <option value=\"Hungary\"> Hungary <\/option>\n                      <option value=\"Iceland\"> Iceland <\/option>\n                      <option value=\"India\"> India <\/option>\n                      <option value=\"Indonesia\"> Indonesia <\/option>\n                      <option value=\"Iran\"> Iran <\/option>\n                      <option value=\"Iraq\"> Iraq <\/option>\n                      <option value=\"Ireland\"> Ireland <\/option>\n                      <option value=\"Israel\"> Israel <\/option>\n                      <option value=\"Italy\"> Italy <\/option>\n                      <option value=\"Jamaica\"> Jamaica <\/option>\n                      <option value=\"Japan\"> Japan <\/option>\n                      <option value=\"Jersey\"> Jersey <\/option>\n                      <option value=\"Jordan\"> Jordan <\/option>\n                      <option value=\"Kazakhstan\"> Kazakhstan <\/option>\n                      <option value=\"Kenya\"> Kenya <\/option>\n                      <option value=\"Kiribati\"> Kiribati <\/option>\n                      <option value=\"North Korea\"> North Korea <\/option>\n                      <option value=\"South Korea\"> South Korea <\/option>\n                      <option value=\"Kosovo\"> Kosovo <\/option>\n                      <option value=\"Kuwait\"> Kuwait <\/option>\n                      <option value=\"Kyrgyzstan\"> Kyrgyzstan <\/option>\n                      <option value=\"Laos\"> Laos <\/option>\n                      <option value=\"Latvia\"> Latvia <\/option>\n                      <option value=\"Lebanon\"> Lebanon <\/option>\n                      <option value=\"Lesotho\"> Lesotho <\/option>\n                      <option value=\"Liberia\"> Liberia <\/option>\n                      <option value=\"Libya\"> Libya <\/option>\n                      <option value=\"Liechtenstein\"> Liechtenstein <\/option>\n                      <option value=\"Lithuania\"> Lithuania <\/option>\n                      <option value=\"Luxembourg\"> Luxembourg <\/option>\n                      <option value=\"Macau\"> Macau <\/option>\n                      <option value=\"Macedonia\"> Macedonia <\/option>\n                      <option value=\"Madagascar\"> Madagascar <\/option>\n                      <option value=\"Malawi\"> Malawi <\/option>\n                      <option value=\"Malaysia\"> Malaysia <\/option>\n                      <option value=\"Maldives\"> Maldives <\/option>\n                      <option value=\"Mali\"> Mali <\/option>\n                      <option value=\"Malta\"> Malta <\/option>\n                      <option value=\"Marshall Islands\"> Marshall Islands <\/option>\n                      <option value=\"Martinique\"> Martinique <\/option>\n                      <option value=\"Mauritania\"> Mauritania <\/option>\n                      <option value=\"Mauritius\"> Mauritius <\/option>\n                      <option value=\"Mayotte\"> Mayotte <\/option>\n                      <option value=\"Mexico\"> Mexico <\/option>\n                      <option value=\"Micronesia\"> Micronesia <\/option>\n                      <option value=\"Moldova\"> Moldova <\/option>\n                      <option value=\"Monaco\"> Monaco <\/option>\n                      <option value=\"Mongolia\"> Mongolia <\/option>\n                      <option value=\"Montenegro\"> Montenegro <\/option>\n                      <option value=\"Montserrat\"> Montserrat <\/option>\n                      <option value=\"Morocco\"> Morocco <\/option>\n                      <option value=\"Mozambique\"> Mozambique <\/option>\n                      <option value=\"Myanmar\"> Myanmar <\/option>\n                      <option value=\"Nagorno-Karabakh\"> Nagorno-Karabakh <\/option>\n                      <option value=\"Namibia\"> Namibia <\/option>\n                      <option value=\"Nauru\"> Nauru <\/option>\n                      <option value=\"Nepal\"> Nepal <\/option>\n                      <option value=\"Netherlands\"> Netherlands <\/option>\n                      <option value=\"Netherlands Antilles\"> Netherlands Antilles <\/option>\n                      <option value=\"New Caledonia\"> New Caledonia <\/option>\n                      <option value=\"New Zealand\"> New Zealand <\/option>\n                      <option value=\"Nicaragua\"> Nicaragua <\/option>\n                      <option value=\"Niger\"> Niger <\/option>\n                      <option value=\"Nigeria\"> Nigeria <\/option>\n                      <option value=\"Niue\"> Niue <\/option>\n                      <option value=\"Norfolk Island\"> Norfolk Island <\/option>\n                      <option value=\"Turkish Republic of Northern Cyprus\"> Turkish Republic of Northern Cyprus <\/option>\n                      <option value=\"Northern Mariana\"> Northern Mariana <\/option>\n                      <option value=\"Norway\"> Norway <\/option>\n                      <option value=\"Oman\"> Oman <\/option>\n                      <option value=\"Pakistan\"> Pakistan <\/option>\n                      <option value=\"Palau\"> Palau <\/option>\n                      <option value=\"Palestine\"> Palestine <\/option>\n                      <option value=\"Panama\"> Panama <\/option>\n                      <option value=\"Papua New Guinea\"> Papua New Guinea <\/option>\n                      <option value=\"Paraguay\"> Paraguay <\/option>\n                      <option value=\"Peru\"> Peru <\/option>\n                      <option value=\"Philippines\"> Philippines <\/option>\n                      <option value=\"Pitcairn Islands\"> Pitcairn Islands <\/option>\n                      <option value=\"Poland\"> Poland <\/option>\n                      <option value=\"Portugal\"> Portugal <\/option>\n                      <option value=\"Puerto Rico\"> Puerto Rico <\/option>\n                      <option value=\"Qatar\"> Qatar <\/option>\n                      <option value=\"Republic of the Congo\"> Republic of the Congo <\/option>\n                      <option value=\"Romania\"> Romania <\/option>\n                      <option value=\"Russia\"> Russia <\/option>\n                      <option value=\"Rwanda\"> Rwanda <\/option>\n                      <option value=\"Saint Barthelemy\"> Saint Barthelemy <\/option>\n                      <option value=\"Saint Helena\"> Saint Helena <\/option>\n                      <option value=\"Saint Kitts and Nevis\"> Saint Kitts and Nevis <\/option>\n                      <option value=\"Saint Lucia\"> Saint Lucia <\/option>\n                      <option value=\"Saint Martin\"> Saint Martin <\/option>\n                      <option value=\"Saint Pierre and Miquelon\"> Saint Pierre and Miquelon <\/option>\n                      <option value=\"Saint Vincent and the Grenadines\"> Saint Vincent and the Grenadines <\/option>\n                      <option value=\"Samoa\"> Samoa <\/option>\n                      <option value=\"San Marino\"> San Marino <\/option>\n                      <option value=\"Sao Tome and Principe\"> Sao Tome and Principe <\/option>\n                      <option value=\"Saudi Arabia\"> Saudi Arabia <\/option>\n                      <option value=\"Senegal\"> Senegal <\/option>\n                      <option value=\"Serbia\"> Serbia <\/option>\n                      <option value=\"Seychelles\"> Seychelles <\/option>\n                      <option value=\"Sierra Leone\"> Sierra Leone <\/option>\n                      <option value=\"Singapore\"> Singapore <\/option>\n                      <option value=\"Slovakia\"> Slovakia <\/option>\n                      <option value=\"Slovenia\"> Slovenia <\/option>\n                      <option value=\"Solomon Islands\"> Solomon Islands <\/option>\n                      <option value=\"Somalia\"> Somalia <\/option>\n                      <option value=\"Somaliland\"> Somaliland <\/option>\n                      <option value=\"South Africa\"> South Africa <\/option>\n                      <option value=\"South Ossetia\"> South Ossetia <\/option>\n                      <option value=\"South Sudan\"> South Sudan <\/option>\n                      <option value=\"Spain\"> Spain <\/option>\n                      <option value=\"Sri Lanka\"> Sri Lanka <\/option>\n                      <option value=\"Sudan\"> Sudan <\/option>\n                      <option value=\"Suriname\"> Suriname <\/option>\n                      <option value=\"Svalbard\"> Svalbard <\/option>\n                      <option value=\"eSwatini\"> eSwatini <\/option>\n                      <option value=\"Sweden\"> Sweden <\/option>\n                      <option value=\"Switzerland\"> Switzerland <\/option>\n                      <option value=\"Syria\"> Syria <\/option>\n                      <option value=\"Taiwan\"> Taiwan <\/option>\n                      <option value=\"Tajikistan\"> Tajikistan <\/option>\n                      <option value=\"Tanzania\"> Tanzania <\/option>\n                      <option value=\"Thailand\"> Thailand <\/option>\n                      <option value=\"Timor-Leste\"> Timor-Leste <\/option>\n                      <option value=\"Togo\"> Togo <\/option>\n                      <option value=\"Tokelau\"> Tokelau <\/option>\n                      <option value=\"Tonga\"> Tonga <\/option>\n                      <option value=\"Transnistria Pridnestrovie\"> Transnistria Pridnestrovie <\/option>\n                      <option value=\"Trinidad and Tobago\"> Trinidad and Tobago <\/option>\n                      <option value=\"Tristan da Cunha\"> Tristan da Cunha <\/option>\n                      <option value=\"Tunisia\"> Tunisia <\/option>\n                      <option value=\"Turkey\"> Turkey <\/option>\n                      <option value=\"Turkmenistan\"> Turkmenistan <\/option>\n                      <option value=\"Turks and Caicos Islands\"> Turks and Caicos Islands <\/option>\n                      <option value=\"Tuvalu\"> Tuvalu <\/option>\n                      <option value=\"Uganda\"> Uganda <\/option>\n                      <option value=\"Ukraine\"> Ukraine <\/option>\n                      <option value=\"United Arab Emirates\"> United Arab Emirates <\/option>\n                      <option value=\"United Kingdom\"> United Kingdom <\/option>\n                      <option value=\"Uruguay\"> Uruguay <\/option>\n                      <option value=\"Uzbekistan\"> Uzbekistan <\/option>\n                      <option value=\"Vanuatu\"> Vanuatu <\/option>\n                      <option value=\"Vatican City\"> Vatican City <\/option>\n                      <option value=\"Venezuela\"> Venezuela <\/option>\n                      <option value=\"Vietnam\"> Vietnam <\/option>\n                      <option value=\"British Virgin Islands\"> British Virgin Islands <\/option>\n                      <option value=\"Isle of Man\"> Isle of Man <\/option>\n                      <option value=\"US Virgin Islands\"> US Virgin Islands <\/option>\n                      <option value=\"Wallis and Futuna\"> Wallis and Futuna <\/option>\n                      <option value=\"Western Sahara\"> Western Sahara <\/option>\n                      <option value=\"Yemen\"> Yemen <\/option>\n                      <option value=\"Zambia\"> Zambia <\/option>\n                      <option value=\"Zimbabwe\"> Zimbabwe <\/option>\n                      <option value=\"other\"> Other <\/option>\n                    <\/select>\n                    <label class=\"form-sub-label\" for=\"input_17_country\" id=\"sublabel_17_country\" style=\"min-height:13px\"> Country <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n            <\/tbody>\n          <\/table>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_18\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_18\" for=\"input_18\"> Diagnosis <\/label>\n        <div id=\"cid_18\" class=\"form-input-wide\">\n          <textarea id=\"input_18\" class=\"form-textarea\" name=\"q18_diagnosis\" cols=\"40\" rows=\"6\" data-component=\"textarea\" aria-labelledby=\"label_18\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_29\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_29\" for=\"input_29\">\n          Reason for referral\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_29\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_29\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_29_0\" name=\"q29_reasonFor29\" value=\"Asthma Education Session\" required=\"\" \/>\n              <label id=\"label_input_29_0\" for=\"input_29_0\"> Asthma Education Session <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_29_1\" name=\"q29_reasonFor29\" value=\"COPD Education Session\" required=\"\" \/>\n              <label id=\"label_input_29_1\" for=\"input_29_1\"> COPD Education Session <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_29_2\" name=\"q29_reasonFor29\" value=\"Spirometry\" required=\"\" \/>\n              <label id=\"label_input_29_2\" for=\"input_29_2\"> Spirometry <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <input type=\"radio\" class=\"form-radio-other form-radio validate[required]\" name=\"q29_reasonFor29\" id=\"other_29\" value=\"other\" \/>\n              <label id=\"label_other_29\" style=\"text-indent:0\" for=\"other_29\">  <\/label>\n              <input type=\"text\" class=\"form-radio-other-input form-textbox\" name=\"q29_reasonFor29[other]\" data-otherhint=\"Other\" placeholder=\"Other\" size=\"15\" id=\"input_29\" \/>\n              <br\/>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_20\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_20\" for=\"input_20\"> Current medications and other relevant information <\/label>\n        <div id=\"cid_20\" class=\"form-input-wide\">\n          <textarea id=\"input_20\" class=\"form-textarea\" name=\"q20_currentMedications\" cols=\"40\" rows=\"6\" data-component=\"textarea\" aria-labelledby=\"label_20\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_21\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_21\" for=\"input_21\">\n          Verbal informed consent for referral obtained\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_21\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_21\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_21_0\" name=\"q21_verbalInformed\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_21_0\" for=\"input_21_0\"> Yes <\/label>\n            <\/span>\n        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