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class=\"form-all\">\n    <link type=\"text\/css\" rel=\"stylesheet\" media=\"all\" href=\"https:\/\/cdn.jotfor.ms\/wizards\/languageWizard\/custom-dropdown\/css\/lang-dd.css?3.3.13125\" \/>\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\" class=\"en\">\n            English (US)\n          <\/li>\n        <\/ul>\n      <\/div>\n    <\/div>\n    <script type=\"text\/javascript\" src=\"https:\/\/cdn.jotfor.ms\/js\/formTranslation.v2.js?3.3.13125\"><\/script>\n    <ul class=\"form-section page-section\">\n      <li id=\"cid_1\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_1\" class=\"form-header\" data-component=\"header\">\n              Patient Registration\n            <\/h2>\n            <div id=\"subHeader_1\" class=\"form-subHeader\">\n              To make your visit more smooth and efficient, please fill the below online form before coming to us.\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_3\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_3\" class=\"form-header\" data-component=\"header\">\n              Your Details\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_4\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_4\" for=\"first_4\">\n          Name\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_name[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_name[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          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_datetime\" id=\"id_5\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_5\" for=\"lite_mode_5\">\n          Date of Birth\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_5\" 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_5\" name=\"q5_dateOf[day]\" size=\"2\" data-maxlength=\"2\" value=\"\" required=\"\" aria-labelledby=\"label_5 sublabel_5_day\" \/>\n                <span class=\"date-separate\" aria-hidden=\"true\">\n       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name=\"q5_dateOf[year]\" size=\"4\" data-maxlength=\"4\" value=\"\" required=\"\" aria-labelledby=\"label_5 sublabel_5_year\" \/>\n                <label class=\"form-sub-label\" for=\"year_5\" id=\"sublabel_5_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_5\" size=\"12\" data-maxlength=\"12\" data-age=\"\" value=\"\" required=\"\" data-format=\"ddmmyyyy\" data-seperator=\"-\" placeholder=\"dd-mm-yyyy\" aria-labelledby=\"label_5 sublabel_5_litemode\" \/>\n              <img alt=\"Pick a Date\" id=\"input_5_pick\" src=\"https:\/\/cdn.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_5\" id=\"sublabel_5_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_5_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_email\" id=\"id_6\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_6\" for=\"input_6\">\n          Email\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_6\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <input type=\"email\" id=\"input_6\" name=\"q6_email\" class=\"form-textbox validate[required, Email]\" size=\"30\" value=\"\" data-component=\"email\" aria-labelledby=\"label_6 sublabel_input_6\" required=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_6\" id=\"sublabel_input_6\" style=\"min-height:13px\"> example@example.com <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_address\" id=\"id_7\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_7\" for=\"input_7_addr_line1\">\n          Address\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_7\" class=\"form-input-wide jf-required\">\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_7_addr_line1\" name=\"q7_address[addr_line1]\" class=\"form-textbox validate[required] form-address-line\" autoComplete=\"address-line1\" value=\"\" data-component=\"address_line_1\" aria-labelledby=\"label_7 sublabel_7_addr_line1\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_7_addr_line1\" id=\"sublabel_7_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_7_addr_line2\" name=\"q7_address[addr_line2]\" class=\"form-textbox form-address-line\" autoComplete=\"address-line2\" size=\"46\" value=\"\" data-component=\"address_line_2\" aria-labelledby=\"label_7 sublabel_7_addr_line2\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_7_addr_line2\" id=\"sublabel_7_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_7_city\" name=\"q7_address[city]\" class=\"form-textbox validate[required] form-address-city\" autoComplete=\"address-level2\" size=\"21\" value=\"\" data-component=\"city\" aria-labelledby=\"label_7 sublabel_7_city\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_7_city\" id=\"sublabel_7_city\" style=\"min-height:13px\"> City <\/label>\n                  <\/span>\n                <\/td>\n                <td style=\"display:none\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_7_state\" name=\"q7_address[state]\" class=\"form-textbox validate[required] form-address-state\" autoComplete=\"new-password\" size=\"22\" value=\"\" data-component=\"state\" aria-labelledby=\"label_7 sublabel_7_state\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_7_state\" id=\"sublabel_7_state\" style=\"min-height:13px\"> State \/ Province <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td style=\"display:none\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_7_postal\" name=\"q7_address[postal]\" class=\"form-textbox form-address-postal\" autoComplete=\"new-password\" size=\"10\" value=\"\" data-component=\"zip\" aria-labelledby=\"label_7 sublabel_7_postal\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_7_postal\" id=\"sublabel_7_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 validate[required] form-address-country noTranslate\" name=\"q7_address[country]\" id=\"input_7_country\" data-component=\"country\" required=\"\" aria-labelledby=\"label_7 sublabel_7_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_7_country\" id=\"sublabel_7_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 jf-required\" data-type=\"control_phone\" id=\"id_8\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_8\" for=\"input_8_area\">\n          Contact Phone Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_8\" 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_8_area\" name=\"q8_contactPhone[area]\" class=\"form-textbox validate[required]\" size=\"6\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_8 sublabel_8_area\" required=\"\" \/>\n              <span class=\"phone-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_8_area\" id=\"sublabel_8_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_8_phone\" name=\"q8_contactPhone[phone]\" class=\"form-textbox validate[required]\" size=\"12\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_8 sublabel_8_phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_8_phone\" id=\"sublabel_8_phone\" style=\"min-height:13px\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_9\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_9\" for=\"input_9\"> Occupation <\/label>\n        <div id=\"cid_9\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_9\" name=\"q9_occupation\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_9\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_10\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_10\" for=\"input_10\">\n          How did you hear about us?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_10\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_10\" 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_10_0\" name=\"q10_howDid\" value=\"Referred by Dentist\" required=\"\" \/>\n              <label id=\"label_input_10_0\" for=\"input_10_0\"> Referred by Dentist <\/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_10_1\" name=\"q10_howDid\" value=\"Referred by GP\" required=\"\" \/>\n              <label id=\"label_input_10_1\" for=\"input_10_1\"> Referred by GP <\/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_10_2\" name=\"q10_howDid\" value=\"Referred by Internet\" required=\"\" \/>\n              <label id=\"label_input_10_2\" for=\"input_10_2\"> Referred by Internet <\/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_10_3\" name=\"q10_howDid\" value=\"Referred by Radio\" required=\"\" \/>\n              <label id=\"label_input_10_3\" for=\"input_10_3\"> Referred by Radio <\/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_10_4\" name=\"q10_howDid\" value=\"Referred by Newspaper Magazine\" required=\"\" \/>\n              <label id=\"label_input_10_4\" for=\"input_10_4\"> Referred by Newspaper Magazine <\/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_10_5\" name=\"q10_howDid\" value=\"Referred by Yellow Page\" required=\"\" \/>\n              <label id=\"label_input_10_5\" for=\"input_10_5\"> Referred by Yellow Page <\/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_10_6\" name=\"q10_howDid\" value=\"Referred by Friends\" required=\"\" \/>\n              <label id=\"label_input_10_6\" for=\"input_10_6\"> Referred by Friends <\/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_10_7\" name=\"q10_howDid\" value=\"Referred by Other\" required=\"\" \/>\n              <label id=\"label_input_10_7\" for=\"input_10_7\"> Referred by Other <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_51\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_51\" for=\"input_51\">\n          Which NSOMS clinic are you wanting to register for?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_51\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_51\" 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_51_0\" name=\"q51_whichNsoms\" value=\"North Shore\" required=\"\" \/>\n              <label id=\"label_input_51_0\" for=\"input_51_0\"> North Shore <\/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_51_1\" name=\"q51_whichNsoms\" value=\"St Marks\" required=\"\" \/>\n              <label id=\"label_input_51_1\" for=\"input_51_1\"> St Marks <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_11\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_11\" class=\"form-header\" data-component=\"header\">\n              Emergency Contact Details\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_12\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_12\" for=\"first_12\">\n          Emergency Contact Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_12\" 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_12\" name=\"q12_emergencyContact12[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_12 sublabel_12_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_12\" id=\"sublabel_12_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_12\" name=\"q12_emergencyContact12[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_12 sublabel_12_last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_12\" id=\"sublabel_12_last\" style=\"min-height:13px\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_13\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_13\" for=\"input_13\">\n          Emergency Contact Relationship\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_13\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_13\" name=\"q13_emergencyContact13\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_13\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" 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          Emergency Contact 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_emergencyContact14[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_emergencyContact14[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 id=\"cid_15\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_15\" class=\"form-header\" data-component=\"header\">\n              Medical Details\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_16\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_16\" for=\"input_16\">\n          At the present time are you taking any medication or tablets\/or have you taken any medication or tablets during the last 6 months?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_16\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_16\" 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_16_0\" name=\"q16_atThe16\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_16_0\" for=\"input_16_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_16_1\" name=\"q16_atThe16\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_16_1\" for=\"input_16_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_17\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_17\" for=\"input_17\"> If you have answered yes please provide more details <\/label>\n        <div id=\"cid_17\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_17\" name=\"q17_ifYou\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"70\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_17\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_19\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_19\" for=\"input_19\">\n          Are you taking any Vitamins, herbal supplements or homeopathic medication?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_19\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_19\" 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_19_0\" name=\"q19_areYou\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_19_0\" for=\"input_19_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_19_1\" name=\"q19_areYou\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_19_1\" for=\"input_19_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_20\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_20\" for=\"input_20\"> If you have answered yes please provide more details <\/label>\n        <div id=\"cid_20\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_20\" name=\"q20_ifYou20\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"70\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_20\" \/>\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          Have you been under the care of a doctor: or in hospital during the past six months?\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-single-column\" role=\"group\" aria-labelledby=\"label_21\" 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_21_0\" name=\"q21_haveYou\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_21_0\" for=\"input_21_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_21_1\" name=\"q21_haveYou\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_21_1\" for=\"input_21_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_22\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_22\" for=\"input_22\"> If you have answered yes please provide more details <\/label>\n        <div id=\"cid_22\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_22\" name=\"q22_ifYou22\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"70\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_22\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line 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          Have you experienced any allergic\/unusual effects from any tablets, drugs, injections or anaesthetic?\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-single-column\" role=\"group\" aria-labelledby=\"label_23\" 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_23_0\" name=\"q23_haveYou23\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_23_0\" for=\"input_23_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_23_1\" name=\"q23_haveYou23\" 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\" data-type=\"control_textbox\" id=\"id_24\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_24\" for=\"input_24\"> If you have answered yes please provide more details <\/label>\n        <div id=\"cid_24\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_24\" name=\"q24_ifYou24\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"70\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_24\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_25\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_25\" for=\"input_25\"> Please tick if you ever have had any of the following: <\/label>\n        <div id=\"cid_25\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_25\" 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\" id=\"input_25_0\" name=\"q25_pleaseTick\" value=\"Heart Trouble\" \/>\n              <label id=\"label_input_25_0\" for=\"input_25_0\"> Heart Trouble <\/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\" id=\"input_25_1\" name=\"q25_pleaseTick\" value=\"Heart Murmur\" \/>\n              <label id=\"label_input_25_1\" for=\"input_25_1\"> Heart Murmur <\/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\" id=\"input_25_2\" name=\"q25_pleaseTick\" value=\"Arthritis\" \/>\n              <label id=\"label_input_25_2\" for=\"input_25_2\"> Arthritis <\/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\" id=\"input_25_3\" name=\"q25_pleaseTick\" value=\"Asthma\" \/>\n              <label id=\"label_input_25_3\" for=\"input_25_3\"> Asthma <\/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\" id=\"input_25_4\" name=\"q25_pleaseTick\" value=\"Rheumatic fever\" \/>\n              <label id=\"label_input_25_4\" for=\"input_25_4\"> Rheumatic fever <\/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\" id=\"input_25_5\" name=\"q25_pleaseTick\" value=\"Jaundice or Hepatitis\" \/>\n              <label id=\"label_input_25_5\" for=\"input_25_5\"> Jaundice or Hepatitis <\/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\" id=\"input_25_6\" name=\"q25_pleaseTick\" value=\"Anemia\" \/>\n              <label id=\"label_input_25_6\" for=\"input_25_6\"> Anemia <\/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\" id=\"input_25_7\" name=\"q25_pleaseTick\" value=\"Epilepsy\" \/>\n              <label id=\"label_input_25_7\" for=\"input_25_7\"> Epilepsy <\/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\" id=\"input_25_8\" name=\"q25_pleaseTick\" value=\"Diabetes\" \/>\n              <label id=\"label_input_25_8\" for=\"input_25_8\"> Diabetes <\/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\" id=\"input_25_9\" name=\"q25_pleaseTick\" value=\"Bruise Easily\" \/>\n              <label id=\"label_input_25_9\" for=\"input_25_9\"> Bruise Easily <\/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\" id=\"input_25_10\" name=\"q25_pleaseTick\" value=\"Kidney problems\" \/>\n              <label id=\"label_input_25_10\" for=\"input_25_10\"> Kidney problems <\/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\" id=\"input_25_11\" name=\"q25_pleaseTick\" value=\"Blood Pressure High\/Low\" \/>\n              <label id=\"label_input_25_11\" for=\"input_25_11\"> Blood Pressure High\/Low <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_26\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_26\" for=\"input_26\"> Any other medical conditions? Please provide more detail <\/label>\n        <div id=\"cid_26\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_26\" name=\"q26_anyOther\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_26\" \/>\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          Do you have a bleeding problem, such as prolonged bleeding after surgery, anemia, or bruising?\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_doYou\" 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_doYou\" 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 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          Have you had any prosthetic surgery? (e.g heart value or joint replacement)\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_haveYou28\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_28_0\" for=\"input_28_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_28_1\" name=\"q28_haveYou28\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_28_1\" for=\"input_28_1\"> No <\/label>\n            <\/span>\n          <\/div>\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          Are you taking any medications for Osteoporosis e.g. Fosamax, or an Aclasta Infusion?\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_areYou29\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_29_0\" for=\"input_29_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_29_1\" name=\"q29_areYou29\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_29_1\" for=\"input_29_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_30\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_30\" for=\"input_30\">\n          Are you HIV positive?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_30\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_30\" 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_30_0\" name=\"q30_areYou30\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_30_0\" for=\"input_30_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_30_1\" name=\"q30_areYou30\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_30_1\" for=\"input_30_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_31\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_31\" for=\"input_31\"> Are you hepatitis &quot;A&quot; &quot;B&quot; &quot;C&quot; positive? <\/label>\n        <div id=\"cid_31\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_31\" 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\" id=\"input_31_0\" name=\"q31_areYou31\" value=\"Yes\" \/>\n              <label id=\"label_input_31_0\" for=\"input_31_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\" id=\"input_31_1\" name=\"q31_areYou31\" value=\"No\" \/>\n              <label id=\"label_input_31_1\" for=\"input_31_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_32\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_32\" for=\"input_32\"> Do you smoke? <\/label>\n        <div id=\"cid_32\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_32\" 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\" id=\"input_32_0\" name=\"q32_doYou32\" value=\"Yes\" \/>\n              <label id=\"label_input_32_0\" for=\"input_32_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\" id=\"input_32_1\" name=\"q32_doYou32\" value=\"No\" \/>\n              <label id=\"label_input_32_1\" for=\"input_32_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_33\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_33\" for=\"input_33\"> Females: Are\/could you be pregnant? <\/label>\n        <div id=\"cid_33\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_33\" 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\" id=\"input_33_0\" name=\"q33_femalesArecould\" value=\"Yes\" \/>\n              <label id=\"label_input_33_0\" for=\"input_33_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\" id=\"input_33_1\" name=\"q33_femalesArecould\" value=\"No\" \/>\n              <label id=\"label_input_33_1\" for=\"input_33_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_34\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_34\" class=\"form-header\" data-component=\"header\">\n              Insurance Details\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_dropdown\" id=\"id_49\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_49\" for=\"input_49\">\n          Do you have medical or dental insurance?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_49\" class=\"form-input-wide jf-required\">\n          <select class=\"form-dropdown validate[required]\" id=\"input_49\" name=\"q49_doYou49\" style=\"width:150px\" data-component=\"dropdown\" required=\"\" aria-labelledby=\"label_49\">\n            <option value=\"\">  <\/option>\n            <option value=\"Yes\"> Yes <\/option>\n            <option value=\"No\"> No <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_35\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_35\" for=\"input_35\"> Insurance provider <\/label>\n        <div id=\"cid_35\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_35\" name=\"q35_insuranceProvider\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_35\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_36\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_36\" for=\"input_36\"> Plan <\/label>\n        <div id=\"cid_36\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_36\" name=\"q36_plan\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_36\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_37\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_37\" for=\"input_37\"> Membership number <\/label>\n        <div id=\"cid_37\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_37\" name=\"q37_membershipNumber\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_37\" \/>\n        <\/div>\n      <\/li>\n      <li id=\"cid_38\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_38\" class=\"form-header\" data-component=\"header\">\n              Additional Details\n            <\/h2>\n            <div id=\"subHeader_38\" class=\"form-subHeader\">\n              Do you have any individual requirements? If yes, please provide more details.\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_39\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_39\" for=\"input_39\"> Language <\/label>\n        <div id=\"cid_39\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_39\" 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\" id=\"input_39_0\" name=\"q39_language\" value=\"Yes\" \/>\n              <label id=\"label_input_39_0\" for=\"input_39_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\" id=\"input_39_1\" name=\"q39_language\" value=\"No\" \/>\n              <label id=\"label_input_39_1\" for=\"input_39_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_40\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_40\" for=\"input_40\"> Disability <\/label>\n        <div id=\"cid_40\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_40\" 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\" id=\"input_40_0\" name=\"q40_disability\" value=\"Yes\" \/>\n              <label id=\"label_input_40_0\" for=\"input_40_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\" id=\"input_40_1\" name=\"q40_disability\" value=\"No\" \/>\n              <label id=\"label_input_40_1\" for=\"input_40_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_41\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_41\" for=\"input_41\"> Religious, spiritual, cultural or family \/ Whanau <\/label>\n        <div id=\"cid_41\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_41\" 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\" id=\"input_41_0\" name=\"q41_religiousSpiritual\" value=\"Yes\" \/>\n              <label id=\"label_input_41_0\" for=\"input_41_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\" id=\"input_41_1\" name=\"q41_religiousSpiritual\" value=\"No\" \/>\n              <label id=\"label_input_41_1\" for=\"input_41_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_42\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_42\" for=\"input_42\"> Do you want your Extracted Teeth returned. Body parts: if your procedure requires the removal of a body part would you like it returned if this is possible? <\/label>\n        <div id=\"cid_42\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_42\" 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\" id=\"input_42_0\" name=\"q42_doYou42\" value=\"Yes\" \/>\n              <label id=\"label_input_42_0\" for=\"input_42_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\" id=\"input_42_1\" name=\"q42_doYou42\" value=\"No\" \/>\n              <label id=\"label_input_42_1\" for=\"input_42_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_43\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_43\" for=\"input_43\"> Is there anything else we need to know to help us plan your care? Please detail below. You will have the opportunity to discuss this with your nurse \/ surgeon prior to your surgery? <\/label>\n        <div id=\"cid_43\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_43\" 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\" id=\"input_43_0\" name=\"q43_isThere\" value=\"Yes\" \/>\n              <label id=\"label_input_43_0\" for=\"input_43_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\" id=\"input_43_1\" name=\"q43_isThere\" value=\"No\" \/>\n              <label id=\"label_input_43_1\" for=\"input_43_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_44\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_44\" for=\"input_44\"> If you have answered yes to any of the above, please provide more details <\/label>\n        <div id=\"cid_44\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_44\" name=\"q44_ifYou44\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"70\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_44\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_47\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_47\" for=\"input_47\"> Health information: It may be necessary to release health information to your insurance provider \/ funder to obtain prior approval. I acknowledge that the information provided above is true and accurate. <\/label>\n        <div id=\"cid_47\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_47\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox\" id=\"input_47_0\" name=\"q47_typeA47[]\" value=\"I also agree that the information provided above could be released to your insurance provider\/funder to obtain prior approval or to check details of your treatment upon request.\" \/>\n              <label id=\"label_input_47_0\" for=\"input_47_0\"> I also agree that the information provided above could be released to your insurance provider\/funder to obtain prior approval or to check details of your treatment upon request. <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_button\" id=\"id_2\">\n        <div id=\"cid_2\" class=\"form-input-wide\">\n          <div style=\"text-align:left\" class=\"form-buttons-wrapper \">\n            <button id=\"input_2\" type=\"submit\" class=\"form-submit-button\" data-component=\"button\">\n              Register\n            <\/button>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li style=\"display:none\">\n        Should be Empty:\n        <input type=\"text\" name=\"website\" value=\"\" \/>\n      <\/li>\n    <\/ul>\n  <\/div>\n  <script>\n  JotForm.showJotFormPowered = \"0\";\n  <\/script>\n  <input type=\"hidden\" id=\"simple_spc\" name=\"simple_spc\" value=\"91037878399879\" \/>\n  <script type=\"text\/javascript\">\n  document.getElementById(\"si\" + \"mple\" + \"_spc\").value = \"91037878399879-91037878399879\";\n  <\/script>\n<\/form><\/body>\n<\/html>\n","Patient Registration",Array);(function(){window.handleIFrameMessage=function(e){if(!e.data||!e.data.split)return;var args=e.data.split(":");if(args[2]!="91037878399879"){return;}
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