{"id":1821,"date":"2025-02-25T14:30:27","date_gmt":"2025-02-25T14:30:27","guid":{"rendered":"https:\/\/cad.healthcare\/contact\/"},"modified":"2025-05-12T14:05:26","modified_gmt":"2025-05-12T14:05:26","slug":"contact","status":"publish","type":"page","link":"https:\/\/cad.healthcare\/en\/contact\/","title":{"rendered":"Contact"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;Sezione&#8221; module_id=&#8221;intro&#8221; _builder_version=&#8221;4.27.4&#8243; background_image=&#8221;https:\/\/cad.healthcare\/wp-content\/uploads\/2025\/03\/imgContatti-1.jpg&#8221; background_position=&#8221;top_center&#8221; background_vertical_offset=&#8221;70%&#8221; custom_margin=&#8221;||||false|false&#8221; custom_padding=&#8221;0px||0px||false|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;1&#8243; make_equal=&#8221;on&#8221; _builder_version=&#8221;4.27.4&#8243; background_color=&#8221;rgba(33,61,89,0.52)&#8221; width=&#8221;100%&#8221; custom_padding=&#8221;148px||0px|1px|false|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.27.4&#8243; custom_padding=&#8221;90px|60px|50px|111px|false|false&#8221; custom_padding_tablet=&#8221;140px|40px|20px|40px|false|false&#8221; custom_padding_phone=&#8221;0px|||22px|false|false&#8221; custom_padding_last_edited=&#8221;on|tablet&#8221; custom_css_main_element=&#8221;margin-top:-100px&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text admin_label=&#8221;Titolo H1 introduzione sito&#8221; _builder_version=&#8221;4.27.4&#8243; text_font=&#8221;&#8211;et_global_body_font||||||||&#8221; text_font_size=&#8221;15px&#8221; text_letter_spacing=&#8221;0.5px&#8221; text_line_height=&#8221;1.4em&#8221; header_font=&#8221;&#8211;et_global_body_font||||||||&#8221; header_text_color=&#8221;#FFFFFF&#8221; header_font_size=&#8221;80px&#8221; header_2_font=&#8221;Nunito||||||||&#8221; header_2_text_color=&#8221;#FFFFFF&#8221; header_2_font_size=&#8221;42px&#8221; custom_margin=&#8221;||30px||false|false&#8221; custom_padding=&#8221;|0px||||&#8221; animation_style=&#8221;slide&#8221; animation_direction=&#8221;bottom&#8221; animation_intensity_slide=&#8221;5%&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h1><b>Do you need<\/b><br \/>\n help<b>?<\/b><\/span><\/h1>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; module_id=&#8221;intro&#8221; _builder_version=&#8221;4.27.4&#8243; custom_margin=&#8221;||0px||false|false&#8221; custom_padding=&#8221;16px||9px|||&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row column_structure=&#8221;1_2,1_2&#8243; use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;1&#8243; custom_padding_last_edited=&#8221;on|tablet&#8221; _builder_version=&#8221;4.27.4&#8243; width=&#8221;90%&#8221; custom_padding=&#8221;53px||0px|||&#8221; custom_padding_tablet=&#8221;0px||||false|false&#8221; custom_padding_phone=&#8221;0px||||false|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.27.4&#8243; custom_padding=&#8221;0px||70px||false|false&#8221; custom_padding_tablet=&#8221;0px||70px||false|false&#8221; custom_padding_phone=&#8221;0px|10px|50px|10px|false|false&#8221; custom_padding_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text admin_label=&#8221;I nostri articoli&#8221; _builder_version=&#8221;4.27.4&#8243; text_font_size=&#8221;20px&#8221; header_2_font=&#8221;Nunito|600|||||||&#8221; header_2_font_size=&#8221;50px&#8221; header_3_text_color=&#8221;#213D59&#8243; header_3_font_size=&#8221;34px&#8221; header_4_line_height=&#8221;1.1em&#8221; custom_margin=&#8221;59px|||||&#8221; custom_margin_tablet=&#8221;59px|||||&#8221; custom_margin_phone=&#8221;40px||||false|false&#8221; custom_margin_last_edited=&#8221;on|phone&#8221; custom_padding=&#8221;|0px||||&#8221; animation_style=&#8221;slide&#8221; animation_direction=&#8221;left&#8221; animation_intensity_slide=&#8221;5%&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>We are available to answer any questions you may have and evaluate together the best solution for your service needs.<\/p>\n<p>[\/et_pb_text][\/et_pb_column][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text admin_label=&#8221;Titolo H1 introduzione sito&#8221; _builder_version=&#8221;4.27.4&#8243; text_font=&#8221;&#8211;et_global_body_font||||||||&#8221; text_font_size=&#8221;15px&#8221; text_letter_spacing=&#8221;0.5px&#8221; text_line_height=&#8221;1.4em&#8221; link_text_color=&#8221;#71C9FF&#8221; header_font=&#8221;Helvetica Neue Bold||||||||&#8221; header_font_size=&#8221;80px&#8221; text_orientation=&#8221;right&#8221; max_width=&#8221;74%&#8221; module_alignment=&#8221;right&#8221; custom_margin=&#8221;54px||21px||false|false&#8221; custom_margin_tablet=&#8221;0px||21px||false|false&#8221; custom_margin_phone=&#8221;0px||21px||false|false&#8221; custom_margin_last_edited=&#8221;on|tablet&#8221; animation_style=&#8221;fade&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h3><a href=\"tel:41919719794\"><strong>+41 91 971 97 94<\/strong><\/a><br \/><strong><a href=\"mailto:info@cad.healthcare\">info@cad.healthcare<\/a><\/strong><br \/><strong>Lugano (CH)<\/strong><\/h3>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; module_id=&#8221;contactPatient&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#F6F6F6&#8243; custom_margin=&#8221;-2px|||||&#8221; custom_padding=&#8221;36px|||||&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;1&#8243; _builder_version=&#8221;4.27.4&#8243; width=&#8221;90%&#8221; custom_padding=&#8221;24px||0px||false|false&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.27.4&#8243; custom_padding=&#8221;|80px|||false|false&#8221; custom_padding_tablet=&#8221;|80px|||false|false&#8221; custom_padding_phone=&#8221;|0px|||false|false&#8221; custom_padding_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text content_tablet=&#8221;<\/p>\n<h2 class=%22p1%22>Select the type of <b>contact you need<\/b>.<\/h2>\n<p>&#8221; content_phone=&#8221;<\/p>\n<h2 class=%22p1%22>Select the type of <b>contact you need<\/b>.<\/h2>\n<p>&#8221; content_last_edited=&#8221;off|desktop&#8221; admin_label=&#8221;I nostri articoli&#8221; _builder_version=&#8221;4.27.4&#8243; header_2_font=&#8221;Nunito|600|||||||&#8221; header_2_font_size=&#8221;50px&#8221; header_3_text_color=&#8221;#213D59&#8243; header_3_font_size=&#8221;34px&#8221; custom_margin=&#8221;10px|||||&#8221; custom_padding=&#8221;|42px||||&#8221; custom_padding_tablet=&#8221;|42px||||&#8221; custom_padding_phone=&#8221;|0px|||false|false&#8221; custom_padding_last_edited=&#8221;on|phone&#8221; animation_style=&#8221;slide&#8221; animation_direction=&#8221;left&#8221; animation_intensity_slide=&#8221;5%&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2 class=\"p1\">Select the<br \/><b>contact form<\/b> <br \/>you need.<\/h2>\n<p>[\/et_pb_text][wpforms_selector form_id=&#8221;58&#8243; module_class=&#8221;formScelta&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][\/wpforms_selector][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Do you need help?We are available to answer any questions you may have and evaluate together the best solution for your service needs.+41 91 971 97 94info@cad.healthcareLugano (CH)Select thecontact form you need.<div class=\"et_pb_module wpforms_selector wpforms_selector_0 formScelta\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t<div class=\"wpforms-container wpforms-container-full stileNormale\" id=\"wpforms-58\"><form id=\"wpforms-form-58\" class=\"wpforms-validate wpforms-form\" data-formid=\"58\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/en\/wp-json\/wp\/v2\/pages\/1821\" data-token=\"464ea559c5d6941eff702264168a2c77\" data-token-time=\"1778027366\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-58-field_9-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"9\"><label class=\"wpforms-field-label wpforms-label-hide\">Type of contact required: <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_9\" class=\"wpforms-field-required wpforms-image-choices wpforms-image-choices-modern\"><li class=\"choice-1 depth-1 wpforms-image-choices-item wpforms-selected\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_9_1\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/cad.healthcare\/wp-content\/uploads\/2025\/03\/icona-modulo-contatti.png\" alt=\"Contact Patients\" title=\"Contact Patients\"><\/span><input type=\"radio\" id=\"wpforms-58-field_9_1\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][9]\" value=\"Contact Patients\" tabindex=\"-1\" required  checked='checked'><span class=\"wpforms-image-choices-label\">Contact Patients<\/span><\/label><\/li><li class=\"choice-2 depth-1 wpforms-image-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_9_2\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/cad.healthcare\/wp-content\/uploads\/2025\/03\/icone-srtuttura-contatti.png\" alt=\"Contact Hospitals\/Clinics\" title=\"Contact Hospitals\/Clinics\"><\/span><input type=\"radio\" id=\"wpforms-58-field_9_2\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][9]\" value=\"Contact Hospitals\/Clinics\" tabindex=\"-1\" required ><span class=\"wpforms-image-choices-label\">Contact Hospitals\/Clinics<\/span><\/label><\/li><li class=\"choice-3 depth-1 wpforms-image-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_9_3\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/cad.healthcare\/wp-content\/uploads\/2025\/03\/icona-medico-curante-contatti.png\" alt=\"Contact Primary Care Physicians\" title=\"Contact Primary Care Physicians\"><\/span><input type=\"radio\" id=\"wpforms-58-field_9_3\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][9]\" value=\"Contact Primary Care Physicians\" tabindex=\"-1\" required ><span class=\"wpforms-image-choices-label\">Contact Primary Care Physicians<\/span><\/label><\/li><\/ul><\/div><div id=\"wpforms-58-field_10-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"10\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tPatient data\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_3-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"3\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_3\">First name last name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_3\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][3]\" placeholder=\"First and Last Name\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_13-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"13\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_13\">Date of birth <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_13\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][13][date]\" placeholder=\"Date of birth\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_105-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"105\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_105\">Nation<\/label><select id=\"wpforms-58-field_105\" class=\"wpforms-field-large\" name=\"wpforms[fields][105]\"><option value=\"\" class=\"placeholder\" disabled >Nation<\/option><option value=\"Afghanistan\"  class=\"choice-4 depth-1\"  >Afghanistan<\/option><option value=\"Albania\"  class=\"choice-5 depth-1\"  >Albania<\/option><option value=\"Algeria\"  class=\"choice-6 depth-1\"  >Algeria<\/option><option value=\"Andorra\"  class=\"choice-7 depth-1\"  >Andorra<\/option><option value=\"Angola\"  class=\"choice-8 depth-1\"  >Angola<\/option><option value=\"Eel\"  class=\"choice-9 depth-1\"  >Eel<\/option><option value=\"Antarctica\"  class=\"choice-10 depth-1\"  >Antarctica<\/option><option value=\"Antigua and Barbuda\"  class=\"choice-11 depth-1\"  >Antigua and Barbuda<\/option><option value=\"Saudi Arabia\"  class=\"choice-12 depth-1\"  >Saudi Arabia<\/option><option value=\"Argentina\"  class=\"choice-13 depth-1\"  >Argentina<\/option><option value=\"Armenia\"  class=\"choice-14 depth-1\"  >Armenia<\/option><option value=\"Aruba\"  class=\"choice-15 depth-1\"  >Aruba<\/option><option value=\"Australia\"  class=\"choice-16 depth-1\"  >Australia<\/option><option value=\"Austria\"  class=\"choice-17 depth-1\"  >Austria<\/option><option value=\"Azerbaijan\"  class=\"choice-18 depth-1\"  >Azerbaijan<\/option><option value=\"Bahamas\"  class=\"choice-19 depth-1\"  >Bahamas<\/option><option value=\"Bahrain\"  class=\"choice-20 depth-1\"  >Bahrain<\/option><option value=\"Bangladesh\"  class=\"choice-21 depth-1\"  >Bangladesh<\/option><option value=\"Barbados\"  class=\"choice-22 depth-1\"  >Barbados<\/option><option value=\"Belgium\"  class=\"choice-23 depth-1\"  >Belgium<\/option><option value=\"Belize\"  class=\"choice-24 depth-1\"  >Belize<\/option><option value=\"Benin\"  class=\"choice-25 depth-1\"  >Benin<\/option><option value=\"Bermuda\"  class=\"choice-26 depth-1\"  >Bermuda<\/option><option value=\"Bhutan\"  class=\"choice-27 depth-1\"  >Bhutan<\/option><option value=\"Belarus\"  class=\"choice-28 depth-1\"  >Belarus<\/option><option value=\"Burma\"  class=\"choice-29 depth-1\"  >Burma<\/option><option value=\"Bolivia (plurinational state of)\"  class=\"choice-30 depth-1\"  >Bolivia (plurinational state of)<\/option><option value=\"Bonaire, Saint Eustatius and Saba\"  class=\"choice-31 depth-1\"  >Bonaire, Saint Eustatius and Saba<\/option><option value=\"Bosnia-Herzegovina\"  class=\"choice-32 depth-1\"  >Bosnia-Herzegovina<\/option><option value=\"Botswana\"  class=\"choice-33 depth-1\"  >Botswana<\/option><option value=\"Brazil\"  class=\"choice-34 depth-1\"  >Brazil<\/option><option value=\"Brunei Darrussalam\"  class=\"choice-35 depth-1\"  >Brunei Darrussalam<\/option><option value=\"Bulgaria\"  class=\"choice-36 depth-1\"  >Bulgaria<\/option><option value=\"Burkina Faso\"  class=\"choice-37 depth-1\"  >Burkina Faso<\/option><option value=\"Burundi\"  class=\"choice-38 depth-1\"  >Burundi<\/option><option value=\"Cambodia\"  class=\"choice-39 depth-1\"  >Cambodia<\/option><option value=\"Cameroon\"  class=\"choice-40 depth-1\"  >Cameroon<\/option><option value=\"Canada\"  class=\"choice-41 depth-1\"  >Canada<\/option><option value=\"Cape Verde\"  class=\"choice-42 depth-1\"  >Cape Verde<\/option><option value=\"Chad\"  class=\"choice-43 depth-1\"  >Chad<\/option><option value=\"Chile\"  class=\"choice-44 depth-1\"  >Chile<\/option><option value=\"China\"  class=\"choice-45 depth-1\"  >China<\/option><option value=\"Cyprus\"  class=\"choice-46 depth-1\"  >Cyprus<\/option><option value=\"Colombia\"  class=\"choice-47 depth-1\"  >Colombia<\/option><option value=\"Comoros\"  class=\"choice-48 depth-1\"  >Comoros<\/option><option value=\"Congo\"  class=\"choice-49 depth-1\"  >Congo<\/option><option value=\"Congo (Democratic Republic of the)\"  class=\"choice-50 depth-1\"  >Congo (Democratic Republic of the)<\/option><option value=\"Costa Rica\"  class=\"choice-51 depth-1\"  >Costa Rica<\/option><option value=\"Ivory Coast\"  class=\"choice-52 depth-1\"  >Ivory Coast<\/option><option value=\"Croatia\"  class=\"choice-53 depth-1\"  >Croatia<\/option><option value=\"Cuba\"  class=\"choice-54 depth-1\"  >Cuba<\/option><option value=\"Cura\u00e7ao\"  class=\"choice-55 depth-1\"  >Cura\u00e7ao<\/option><option value=\"Denmark\"  class=\"choice-56 depth-1\"  >Denmark<\/option><option value=\"Dominica\"  class=\"choice-57 depth-1\"  >Dominica<\/option><option value=\"Ecuador\"  class=\"choice-58 depth-1\"  >Ecuador<\/option><option value=\"Egypt\"  class=\"choice-59 depth-1\"  >Egypt<\/option><option value=\"El Salvador\"  class=\"choice-60 depth-1\"  >El Salvador<\/option><option value=\"United Arab Emirates\"  class=\"choice-61 depth-1\"  >United Arab Emirates<\/option><option value=\"Eritrea\"  class=\"choice-62 depth-1\"  >Eritrea<\/option><option value=\"Estonia\"  class=\"choice-63 depth-1\"  >Estonia<\/option><option value=\"Ethiopia\"  class=\"choice-64 depth-1\"  >Ethiopia<\/option><option value=\"Russian Federation\"  class=\"choice-65 depth-1\"  >Russian Federation<\/option><option value=\"Fiji\"  class=\"choice-66 depth-1\"  >Fiji<\/option><option value=\"Philippines\"  class=\"choice-67 depth-1\"  >Philippines<\/option><option value=\"Finland\"  class=\"choice-68 depth-1\"  >Finland<\/option><option value=\"France\"  class=\"choice-69 depth-1\"  >France<\/option><option value=\"Gabon\"  class=\"choice-70 depth-1\"  >Gabon<\/option><option value=\"Gambia\"  class=\"choice-71 depth-1\"  >Gambia<\/option><option value=\"Georgia\"  class=\"choice-72 depth-1\"  >Georgia<\/option><option value=\"South Georgia and the South Sandwich Islands\"  class=\"choice-73 depth-1\"  >South Georgia and the South Sandwich Islands<\/option><option value=\"Germany\"  class=\"choice-74 depth-1\"  >Germany<\/option><option value=\"Ghana\"  class=\"choice-75 depth-1\"  >Ghana<\/option><option value=\"Jamaica\"  class=\"choice-76 depth-1\"  >Jamaica<\/option><option value=\"Japan\"  class=\"choice-77 depth-1\"  >Japan<\/option><option value=\"Gibraltar\"  class=\"choice-78 depth-1\"  >Gibraltar<\/option><option value=\"Djibouti\"  class=\"choice-79 depth-1\"  >Djibouti<\/option><option value=\"Jordan\"  class=\"choice-80 depth-1\"  >Jordan<\/option><option value=\"Greece\"  class=\"choice-81 depth-1\"  >Greece<\/option><option value=\"Grenada\"  class=\"choice-82 depth-1\"  >Grenada<\/option><option value=\"Greenland\"  class=\"choice-83 depth-1\"  >Greenland<\/option><option value=\"Guadeloupe\"  class=\"choice-84 depth-1\"  >Guadeloupe<\/option><option value=\"Guam\"  class=\"choice-85 depth-1\"  >Guam<\/option><option value=\"Guatemala\"  class=\"choice-86 depth-1\"  >Guatemala<\/option><option value=\"Guernsey\"  class=\"choice-87 depth-1\"  >Guernsey<\/option><option value=\"French Guiana\"  class=\"choice-88 depth-1\"  >French Guiana<\/option><option value=\"Guinea\"  class=\"choice-89 depth-1\"  >Guinea<\/option><option value=\"Equatorial Guinea\"  class=\"choice-90 depth-1\"  >Equatorial Guinea<\/option><option value=\"Guinea-Bissau\"  class=\"choice-91 depth-1\"  >Guinea-Bissau<\/option><option value=\"Guyana\"  class=\"choice-92 depth-1\"  >Guyana<\/option><option value=\"Haiti\"  class=\"choice-93 depth-1\"  >Haiti<\/option><option value=\"Honduras\"  class=\"choice-94 depth-1\"  >Honduras<\/option><option value=\"Hong Kong\"  class=\"choice-95 depth-1\"  >Hong Kong<\/option><option value=\"India\"  class=\"choice-96 depth-1\"  >India<\/option><option value=\"Indonesia\"  class=\"choice-97 depth-1\"  >Indonesia<\/option><option value=\"Iran (Islamic Republic of)\"  class=\"choice-98 depth-1\"  >Iran (Islamic Republic of)<\/option><option value=\"Iraq\"  class=\"choice-99 depth-1\"  >Iraq<\/option><option value=\"Ireland (Republic of)\"  class=\"choice-100 depth-1\"  >Ireland (Republic of)<\/option><option value=\"Iceland\"  class=\"choice-101 depth-1\"  >Iceland<\/option><option value=\"Bouvet Island\"  class=\"choice-102 depth-1\"  >Bouvet Island<\/option><option value=\"Isle of Man\"  class=\"choice-103 depth-1\"  >Isle of Man<\/option><option value=\"Christmas Island\"  class=\"choice-104 depth-1\"  >Christmas Island<\/option><option value=\"Island of Saint Barth\u00e9lemy\"  class=\"choice-105 depth-1\"  >Island of Saint Barth\u00e9lemy<\/option><option value=\"Aland Islands\"  class=\"choice-106 depth-1\"  >Aland Islands<\/option><option value=\"Cayman Islands\"  class=\"choice-107 depth-1\"  >Cayman Islands<\/option><option value=\"Cocos Islands (Keeling)\"  class=\"choice-108 depth-1\"  >Cocos Islands (Keeling)<\/option><option value=\"Cook Islands\"  class=\"choice-109 depth-1\"  >Cook Islands<\/option><option value=\"Falkland Islands (Malvinas)\"  class=\"choice-110 depth-1\"  >Falkland Islands (Malvinas)<\/option><option value=\"Faroe Islands\"  class=\"choice-111 depth-1\"  >Faroe Islands<\/option><option value=\"Heard and McDonald Islands\"  class=\"choice-112 depth-1\"  >Heard and McDonald Islands<\/option><option value=\"Northern Mariana Islands\"  class=\"choice-113 depth-1\"  >Northern Mariana Islands<\/option><option value=\"Marshall Islands\"  class=\"choice-114 depth-1\"  >Marshall Islands<\/option><option value=\"Norfolk Islands\"  class=\"choice-115 depth-1\"  >Norfolk Islands<\/option><option value=\"Saint Pierre and Miquelon Islands\"  class=\"choice-116 depth-1\"  >Saint Pierre and Miquelon Islands<\/option><option value=\"Solomon Islands\"  class=\"choice-117 depth-1\"  >Solomon Islands<\/option><option value=\"Svalbard and Jan Mayen Islands\"  class=\"choice-118 depth-1\"  >Svalbard and Jan Mayen Islands<\/option><option value=\"Turks and Caicos Islands\"  class=\"choice-119 depth-1\"  >Turks and Caicos Islands<\/option><option value=\"Virgin Islands (U.S.)\"  class=\"choice-120 depth-1\"  >Virgin Islands (U.S.)<\/option><option value=\"Virgin Islands (British)\"  class=\"choice-121 depth-1\"  >Virgin Islands (British)<\/option><option value=\"Minor outer islands of the United States of America\"  class=\"choice-122 depth-1\"  >Minor outer islands of the United States of America<\/option><option value=\"Israel\"  class=\"choice-123 depth-1\"  >Israel<\/option><option value=\"Italy\"  class=\"choice-124 depth-1\"  >Italy<\/option><option value=\"Kazakhstan\"  class=\"choice-125 depth-1\"  >Kazakhstan<\/option><option value=\"Kenya\"  class=\"choice-126 depth-1\"  >Kenya<\/option><option value=\"Kyrgyzstan\"  class=\"choice-127 depth-1\"  >Kyrgyzstan<\/option><option value=\"Kiribati\"  class=\"choice-128 depth-1\"  >Kiribati<\/option><option value=\"Korea (People&#039;s Democratic Republic of)\"  class=\"choice-129 depth-1\"  >Korea (People's Democratic Republic of)<\/option><option value=\"Korea (Republic of)\"  class=\"choice-130 depth-1\"  >Korea (Republic of)<\/option><option value=\"Kosovo\"  class=\"choice-131 depth-1\"  >Kosovo<\/option><option value=\"Kuwait\"  class=\"choice-132 depth-1\"  >Kuwait<\/option><option value=\"Lesotho\"  class=\"choice-133 depth-1\"  >Lesotho<\/option><option value=\"Latvia\"  class=\"choice-134 depth-1\"  >Latvia<\/option><option value=\"Lebanon\"  class=\"choice-135 depth-1\"  >Lebanon<\/option><option value=\"Liberia\"  class=\"choice-136 depth-1\"  >Liberia<\/option><option value=\"Libya\"  class=\"choice-137 depth-1\"  >Libya<\/option><option value=\"Liechtenstein\"  class=\"choice-138 depth-1\"  >Liechtenstein<\/option><option value=\"Lithuania\"  class=\"choice-139 depth-1\"  >Lithuania<\/option><option value=\"Luxembourg\"  class=\"choice-140 depth-1\"  >Luxembourg<\/option><option value=\"Macau\"  class=\"choice-141 depth-1\"  >Macau<\/option><option value=\"North Macedonia (Republic of)\"  class=\"choice-142 depth-1\"  >North Macedonia (Republic of)<\/option><option value=\"Madagascar\"  class=\"choice-143 depth-1\"  >Madagascar<\/option><option value=\"Jersey\"  class=\"choice-144 depth-1\"  >Jersey<\/option><option value=\"Malawi\"  class=\"choice-145 depth-1\"  >Malawi<\/option><option value=\"Maldives\"  class=\"choice-146 depth-1\"  >Maldives<\/option><option value=\"Malaysia\"  class=\"choice-147 depth-1\"  >Malaysia<\/option><option value=\"Mali\"  class=\"choice-148 depth-1\"  >Mali<\/option><option value=\"Malta\"  class=\"choice-149 depth-1\"  >Malta<\/option><option value=\"Morocco\"  class=\"choice-150 depth-1\"  >Morocco<\/option><option value=\"Martinique\"  class=\"choice-151 depth-1\"  >Martinique<\/option><option value=\"Mauritania\"  class=\"choice-152 depth-1\"  >Mauritania<\/option><option value=\"Mauritius\"  class=\"choice-153 depth-1\"  >Mauritius<\/option><option value=\"Mayotte\"  class=\"choice-154 depth-1\"  >Mayotte<\/option><option value=\"Mexico\"  class=\"choice-155 depth-1\"  >Mexico<\/option><option value=\"Micronesia (Confederation of States of)\"  class=\"choice-156 depth-1\"  >Micronesia (Confederation of States of)<\/option><option value=\"Moldova (Republic of)\"  class=\"choice-157 depth-1\"  >Moldova (Republic of)<\/option><option value=\"Monaco\"  class=\"choice-158 depth-1\"  >Monaco<\/option><option value=\"Mongolia\"  class=\"choice-159 depth-1\"  >Mongolia<\/option><option value=\"Montenegro\"  class=\"choice-160 depth-1\"  >Montenegro<\/option><option value=\"Montserrat\"  class=\"choice-161 depth-1\"  >Montserrat<\/option><option value=\"Mozambique\"  class=\"choice-162 depth-1\"  >Mozambique<\/option><option value=\"Namibia\"  class=\"choice-163 depth-1\"  >Namibia<\/option><option value=\"Nauru\"  class=\"choice-164 depth-1\"  >Nauru<\/option><option value=\"Nepal\"  class=\"choice-165 depth-1\"  >Nepal<\/option><option value=\"Nicaragua\"  class=\"choice-166 depth-1\"  >Nicaragua<\/option><option value=\"Niger\"  class=\"choice-167 depth-1\"  >Niger<\/option><option value=\"Nigeria\"  class=\"choice-168 depth-1\"  >Nigeria<\/option><option value=\"Niue\"  class=\"choice-169 depth-1\"  >Niue<\/option><option value=\"Norway\"  class=\"choice-170 depth-1\"  >Norway<\/option><option value=\"New Caledonia\"  class=\"choice-171 depth-1\"  >New Caledonia<\/option><option value=\"New Zealand\"  class=\"choice-172 depth-1\"  >New Zealand<\/option><option value=\"Oman\"  class=\"choice-173 depth-1\"  >Oman<\/option><option value=\"Netherlands\"  class=\"choice-174 depth-1\"  >Netherlands<\/option><option value=\"Pakistan\"  class=\"choice-175 depth-1\"  >Pakistan<\/option><option value=\"Palau\"  class=\"choice-176 depth-1\"  >Palau<\/option><option value=\"Palestine (State of)\"  class=\"choice-177 depth-1\"  >Palestine (State of)<\/option><option value=\"Panama\"  class=\"choice-178 depth-1\"  >Panama<\/option><option value=\"Papua New Guinea\"  class=\"choice-179 depth-1\"  >Papua New Guinea<\/option><option value=\"Paraguay\"  class=\"choice-180 depth-1\"  >Paraguay<\/option><option value=\"Peru\"  class=\"choice-181 depth-1\"  >Peru<\/option><option value=\"Pitcairn\"  class=\"choice-182 depth-1\"  >Pitcairn<\/option><option value=\"Poland\"  class=\"choice-183 depth-1\"  >Poland<\/option><option value=\"French Polynesia\"  class=\"choice-184 depth-1\"  >French Polynesia<\/option><option value=\"Puerto Rico\"  class=\"choice-185 depth-1\"  >Puerto Rico<\/option><option value=\"Portugal\"  class=\"choice-186 depth-1\"  >Portugal<\/option><option value=\"Qatar\"  class=\"choice-187 depth-1\"  >Qatar<\/option><option value=\"United Kingdom of Great Britain and Northern Ireland\"  class=\"choice-188 depth-1\"  >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"Arab Republic of Syria\"  class=\"choice-189 depth-1\"  >Arab Republic of Syria<\/option><option value=\"Czech Republic\"  class=\"choice-190 depth-1\"  >Czech Republic<\/option><option value=\"Central African Republic\"  class=\"choice-191 depth-1\"  >Central African Republic<\/option><option value=\"Lao People&#039;s Democratic Republic\"  class=\"choice-192 depth-1\"  >Lao People's Democratic Republic<\/option><option value=\"Dominican Republic\"  class=\"choice-193 depth-1\"  >Dominican Republic<\/option><option value=\"Reunion (Island of)\"  class=\"choice-194 depth-1\"  >Reunion (Island of)<\/option><option value=\"Romania\"  class=\"choice-195 depth-1\"  >Romania<\/option><option value=\"Rwanda\"  class=\"choice-196 depth-1\"  >Rwanda<\/option><option value=\"Western Sahara\"  class=\"choice-197 depth-1\"  >Western Sahara<\/option><option value=\"Saint Kitts and Nevis\"  class=\"choice-198 depth-1\"  >Saint Kitts and Nevis<\/option><option value=\"Saint Vincent and the Grenadines\"  class=\"choice-199 depth-1\"  >Saint Vincent and the Grenadines<\/option><option value=\"Saint-Martin (French Part)\"  class=\"choice-200 depth-1\"  >Saint-Martin (French Part)<\/option><option value=\"Samoa\"  class=\"choice-201 depth-1\"  >Samoa<\/option><option value=\"American Samoa\"  class=\"choice-202 depth-1\"  >American Samoa<\/option><option value=\"San Marino\"  class=\"choice-203 depth-1\"  >San Marino<\/option><option value=\"St. Helena, Ascension and Tristan da Cunha\"  class=\"choice-204 depth-1\"  >St. Helena, Ascension and Tristan da Cunha<\/option><option value=\"Saint Lucia\"  class=\"choice-205 depth-1\"  >Saint Lucia<\/option><option value=\"Sao Tome and Principe\"  class=\"choice-206 depth-1\"  >Sao Tome and Principe<\/option><option value=\"Senegal\"  class=\"choice-207 depth-1\"  >Senegal<\/option><option value=\"Serbia\"  class=\"choice-208 depth-1\"  >Serbia<\/option><option value=\"Seychelles\"  class=\"choice-209 depth-1\"  >Seychelles<\/option><option value=\"Sierra Leone\"  class=\"choice-210 depth-1\"  >Sierra Leone<\/option><option value=\"Singapore\"  class=\"choice-211 depth-1\"  >Singapore<\/option><option value=\"Sint Maarten (part of the Netherlands)\"  class=\"choice-212 depth-1\"  >Sint Maarten (part of the Netherlands)<\/option><option value=\"Slovakia\"  class=\"choice-213 depth-1\"  >Slovakia<\/option><option value=\"Slovenia\"  class=\"choice-214 depth-1\"  >Slovenia<\/option><option value=\"Somalia\"  class=\"choice-215 depth-1\"  >Somalia<\/option><option value=\"Spain\"  class=\"choice-216 depth-1\"  >Spain<\/option><option value=\"Sri Lanka\"  class=\"choice-217 depth-1\"  >Sri Lanka<\/option><option value=\"United States of America\"  class=\"choice-218 depth-1\"  >United States of America<\/option><option value=\"Vatican City State\"  class=\"choice-219 depth-1\"  >Vatican City State<\/option><option value=\"South Africa\"  class=\"choice-220 depth-1\"  >South Africa<\/option><option value=\"Sudan\"  class=\"choice-221 depth-1\"  >Sudan<\/option><option value=\"South Sudan\"  class=\"choice-222 depth-1\"  >South Sudan<\/option><option value=\"Suriname\"  class=\"choice-223 depth-1\"  >Suriname<\/option><option value=\"Sweden\"  class=\"choice-224 depth-1\"  >Sweden<\/option><option value=\"Switzerland\"  selected='selected' class=\"choice-225 depth-1\"  >Switzerland<\/option><option value=\"Tajikistan\"  class=\"choice-226 depth-1\"  >Tajikistan<\/option><option value=\"Taiwan, Republic of China\"  class=\"choice-227 depth-1\"  >Taiwan, Republic of China<\/option><option value=\"Tanzania (United Republic of)\"  class=\"choice-228 depth-1\"  >Tanzania (United Republic of)<\/option><option value=\"French Southern Territories\"  class=\"choice-229 depth-1\"  >French Southern Territories<\/option><option value=\"British territory in the Indian Ocean\"  class=\"choice-230 depth-1\"  >British territory in the Indian Ocean<\/option><option value=\"Thailand\"  class=\"choice-231 depth-1\"  >Thailand<\/option><option value=\"East Timor\"  class=\"choice-232 depth-1\"  >East Timor<\/option><option value=\"Togo\"  class=\"choice-233 depth-1\"  >Togo<\/option><option value=\"Tokelau\"  class=\"choice-234 depth-1\"  >Tokelau<\/option><option value=\"Tonga\"  class=\"choice-235 depth-1\"  >Tonga<\/option><option value=\"Trinidad and Tobago\"  class=\"choice-236 depth-1\"  >Trinidad and Tobago<\/option><option value=\"Tunisia\"  class=\"choice-237 depth-1\"  >Tunisia<\/option><option value=\"Turkey\"  class=\"choice-238 depth-1\"  >Turkey<\/option><option value=\"Turkmenistan\"  class=\"choice-239 depth-1\"  >Turkmenistan<\/option><option value=\"Tuvalu\"  class=\"choice-240 depth-1\"  >Tuvalu<\/option><option value=\"Ukraine\"  class=\"choice-241 depth-1\"  >Ukraine<\/option><option value=\"Uganda\"  class=\"choice-242 depth-1\"  >Uganda<\/option><option value=\"Hungary\"  class=\"choice-243 depth-1\"  >Hungary<\/option><option value=\"Uruguay\"  class=\"choice-244 depth-1\"  >Uruguay<\/option><option value=\"Uzbekistan\"  class=\"choice-245 depth-1\"  >Uzbekistan<\/option><option value=\"Vanuatu\"  class=\"choice-246 depth-1\"  >Vanuatu<\/option><option value=\"Venezuela (Bollivian Republic of)\"  class=\"choice-247 depth-1\"  >Venezuela (Bollivian Republic of)<\/option><option value=\"Vietnam\"  class=\"choice-248 depth-1\"  >Vietnam<\/option><option value=\"Wallis and Futuna\"  class=\"choice-249 depth-1\"  >Wallis and Futuna<\/option><option value=\"Yemen\"  class=\"choice-250 depth-1\"  >Yemen<\/option><option value=\"Zambia\"  class=\"choice-251 depth-1\"  >Zambia<\/option><option value=\"Zimbabwe\"  class=\"choice-252 depth-1\"  >Zimbabwe<\/option><option value=\"eSwatini (Kingdom of)\"  class=\"choice-253 depth-1\"  >eSwatini (Kingdom of)<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_12-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"12\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_12\">Address <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-58-field_12\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][12][address1]\" placeholder=\"Address\" required><label for=\"wpforms-58-field_12\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-58-field_12-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][12][city]\" placeholder=\"City\" required><label for=\"wpforms-58-field_12-city\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-58-field_12-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][12][state]\" placeholder=\"Canton\" required><label for=\"wpforms-58-field_12-state\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">State \/ Province \/ Region<\/label><\/div><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_4-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"4\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_4\">Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-58-field_4\" class=\"wpforms-field-large wpforms-field-required\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][4]\" placeholder=\"Phone\" aria-label=\"Phone\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_1-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"1\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_1\">Email<\/label><input type=\"email\" id=\"wpforms-58-field_1\" class=\"wpforms-field-large\" name=\"wpforms[fields][1]\" placeholder=\"Email\" spellcheck=\"false\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_14-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"14\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tContact information ( If different from the patient )\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_21-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"21\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_21\">first name last name<\/label><input type=\"text\" id=\"wpforms-58-field_21\" class=\"wpforms-field-large\" name=\"wpforms[fields][21]\" placeholder=\"First and Last Name\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_16-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"16\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_16\">Date of birth<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_16\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][16][date]\" placeholder=\"Date of birth\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_107-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"107\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_107\">Country Referent<\/label><select id=\"wpforms-58-field_107\" class=\"wpforms-field-large\" name=\"wpforms[fields][107]\"><option value=\"\" class=\"placeholder\" disabled >Nation<\/option><option value=\"Afghanistan\"  class=\"choice-4 depth-1\"  >Afghanistan<\/option><option value=\"Albania\"  class=\"choice-5 depth-1\"  >Albania<\/option><option value=\"Algeria\"  class=\"choice-6 depth-1\"  >Algeria<\/option><option value=\"Andorra\"  class=\"choice-7 depth-1\"  >Andorra<\/option><option value=\"Angola\"  class=\"choice-8 depth-1\"  >Angola<\/option><option value=\"Eel\"  class=\"choice-9 depth-1\"  >Eel<\/option><option value=\"Antarctica\"  class=\"choice-10 depth-1\"  >Antarctica<\/option><option value=\"Antigua and Barbuda\"  class=\"choice-11 depth-1\"  >Antigua and Barbuda<\/option><option value=\"Saudi Arabia\"  class=\"choice-12 depth-1\"  >Saudi Arabia<\/option><option value=\"Argentina\"  class=\"choice-13 depth-1\"  >Argentina<\/option><option value=\"Armenia\"  class=\"choice-14 depth-1\"  >Armenia<\/option><option value=\"Aruba\"  class=\"choice-15 depth-1\"  >Aruba<\/option><option value=\"Australia\"  class=\"choice-16 depth-1\"  >Australia<\/option><option value=\"Austria\"  class=\"choice-17 depth-1\"  >Austria<\/option><option value=\"Azerbaijan\"  class=\"choice-18 depth-1\"  >Azerbaijan<\/option><option value=\"Bahamas\"  class=\"choice-19 depth-1\"  >Bahamas<\/option><option value=\"Bahrain\"  class=\"choice-20 depth-1\"  >Bahrain<\/option><option value=\"Bangladesh\"  class=\"choice-21 depth-1\"  >Bangladesh<\/option><option value=\"Barbados\"  class=\"choice-22 depth-1\"  >Barbados<\/option><option value=\"Belgium\"  class=\"choice-23 depth-1\"  >Belgium<\/option><option value=\"Belize\"  class=\"choice-24 depth-1\"  >Belize<\/option><option value=\"Benin\"  class=\"choice-25 depth-1\"  >Benin<\/option><option value=\"Bermuda\"  class=\"choice-26 depth-1\"  >Bermuda<\/option><option value=\"Bhutan\"  class=\"choice-27 depth-1\"  >Bhutan<\/option><option value=\"Belarus\"  class=\"choice-28 depth-1\"  >Belarus<\/option><option value=\"Burma\"  class=\"choice-29 depth-1\"  >Burma<\/option><option value=\"Bolivia (plurinational state of)\"  class=\"choice-30 depth-1\"  >Bolivia (plurinational state of)<\/option><option value=\"Bonaire, Saint Eustatius and Saba\"  class=\"choice-31 depth-1\"  >Bonaire, Saint Eustatius and Saba<\/option><option value=\"Bosnia-Herzegovina\"  class=\"choice-32 depth-1\"  >Bosnia-Herzegovina<\/option><option value=\"Botswana\"  class=\"choice-33 depth-1\"  >Botswana<\/option><option value=\"Brazil\"  class=\"choice-34 depth-1\"  >Brazil<\/option><option value=\"Brunei Darrussalam\"  class=\"choice-35 depth-1\"  >Brunei Darrussalam<\/option><option value=\"Bulgaria\"  class=\"choice-36 depth-1\"  >Bulgaria<\/option><option value=\"Burkina Faso\"  class=\"choice-37 depth-1\"  >Burkina Faso<\/option><option value=\"Burundi\"  class=\"choice-38 depth-1\"  >Burundi<\/option><option value=\"Cambodia\"  class=\"choice-39 depth-1\"  >Cambodia<\/option><option value=\"Cameroon\"  class=\"choice-40 depth-1\"  >Cameroon<\/option><option value=\"Canada\"  class=\"choice-41 depth-1\"  >Canada<\/option><option value=\"Cape Verde\"  class=\"choice-42 depth-1\"  >Cape Verde<\/option><option value=\"Chad\"  class=\"choice-43 depth-1\"  >Chad<\/option><option value=\"Chile\"  class=\"choice-44 depth-1\"  >Chile<\/option><option value=\"China\"  class=\"choice-45 depth-1\"  >China<\/option><option value=\"Cyprus\"  class=\"choice-46 depth-1\"  >Cyprus<\/option><option value=\"Colombia\"  class=\"choice-47 depth-1\"  >Colombia<\/option><option value=\"Comoros\"  class=\"choice-48 depth-1\"  >Comoros<\/option><option value=\"Congo\"  class=\"choice-49 depth-1\"  >Congo<\/option><option value=\"Congo (Democratic Republic of the)\"  class=\"choice-50 depth-1\"  >Congo (Democratic Republic of the)<\/option><option value=\"Costa Rica\"  class=\"choice-51 depth-1\"  >Costa Rica<\/option><option value=\"Ivory Coast\"  class=\"choice-52 depth-1\"  >Ivory Coast<\/option><option value=\"Croatia\"  class=\"choice-53 depth-1\"  >Croatia<\/option><option value=\"Cuba\"  class=\"choice-54 depth-1\"  >Cuba<\/option><option value=\"Cura\u00e7ao\"  class=\"choice-55 depth-1\"  >Cura\u00e7ao<\/option><option value=\"Denmark\"  class=\"choice-56 depth-1\"  >Denmark<\/option><option value=\"Dominica\"  class=\"choice-57 depth-1\"  >Dominica<\/option><option value=\"Ecuador\"  class=\"choice-58 depth-1\"  >Ecuador<\/option><option value=\"Egypt\"  class=\"choice-59 depth-1\"  >Egypt<\/option><option value=\"El Salvador\"  class=\"choice-60 depth-1\"  >El Salvador<\/option><option value=\"United Arab Emirates\"  class=\"choice-61 depth-1\"  >United Arab Emirates<\/option><option value=\"Eritrea\"  class=\"choice-62 depth-1\"  >Eritrea<\/option><option value=\"Estonia\"  class=\"choice-63 depth-1\"  >Estonia<\/option><option value=\"Ethiopia\"  class=\"choice-64 depth-1\"  >Ethiopia<\/option><option value=\"Russian Federation\"  class=\"choice-65 depth-1\"  >Russian Federation<\/option><option value=\"Fiji\"  class=\"choice-66 depth-1\"  >Fiji<\/option><option value=\"Philippines\"  class=\"choice-67 depth-1\"  >Philippines<\/option><option value=\"Finland\"  class=\"choice-68 depth-1\"  >Finland<\/option><option value=\"France\"  class=\"choice-69 depth-1\"  >France<\/option><option value=\"Gabon\"  class=\"choice-70 depth-1\"  >Gabon<\/option><option value=\"Gambia\"  class=\"choice-71 depth-1\"  >Gambia<\/option><option value=\"Georgia\"  class=\"choice-72 depth-1\"  >Georgia<\/option><option value=\"South Georgia and the South Sandwich Islands\"  class=\"choice-73 depth-1\"  >South Georgia and the South Sandwich Islands<\/option><option value=\"Germany\"  class=\"choice-74 depth-1\"  >Germany<\/option><option value=\"Ghana\"  class=\"choice-75 depth-1\"  >Ghana<\/option><option value=\"Jamaica\"  class=\"choice-76 depth-1\"  >Jamaica<\/option><option value=\"Japan\"  class=\"choice-77 depth-1\"  >Japan<\/option><option value=\"Gibraltar\"  class=\"choice-78 depth-1\"  >Gibraltar<\/option><option value=\"Djibouti\"  class=\"choice-79 depth-1\"  >Djibouti<\/option><option value=\"Jordan\"  class=\"choice-80 depth-1\"  >Jordan<\/option><option value=\"Greece\"  class=\"choice-81 depth-1\"  >Greece<\/option><option value=\"Grenada\"  class=\"choice-82 depth-1\"  >Grenada<\/option><option value=\"Greenland\"  class=\"choice-83 depth-1\"  >Greenland<\/option><option value=\"Guadeloupe\"  class=\"choice-84 depth-1\"  >Guadeloupe<\/option><option value=\"Guam\"  class=\"choice-85 depth-1\"  >Guam<\/option><option value=\"Guatemala\"  class=\"choice-86 depth-1\"  >Guatemala<\/option><option value=\"Guernsey\"  class=\"choice-87 depth-1\"  >Guernsey<\/option><option value=\"French Guiana\"  class=\"choice-88 depth-1\"  >French Guiana<\/option><option value=\"Guinea\"  class=\"choice-89 depth-1\"  >Guinea<\/option><option value=\"Equatorial Guinea\"  class=\"choice-90 depth-1\"  >Equatorial Guinea<\/option><option value=\"Guinea-Bissau\"  class=\"choice-91 depth-1\"  >Guinea-Bissau<\/option><option value=\"Guyana\"  class=\"choice-92 depth-1\"  >Guyana<\/option><option value=\"Haiti\"  class=\"choice-93 depth-1\"  >Haiti<\/option><option value=\"Honduras\"  class=\"choice-94 depth-1\"  >Honduras<\/option><option value=\"Hong Kong\"  class=\"choice-95 depth-1\"  >Hong Kong<\/option><option value=\"India\"  class=\"choice-96 depth-1\"  >India<\/option><option value=\"Indonesia\"  class=\"choice-97 depth-1\"  >Indonesia<\/option><option value=\"Iran (Islamic Republic of)\"  class=\"choice-98 depth-1\"  >Iran (Islamic Republic of)<\/option><option value=\"Iraq\"  class=\"choice-99 depth-1\"  >Iraq<\/option><option value=\"Ireland (Republic of)\"  class=\"choice-100 depth-1\"  >Ireland (Republic of)<\/option><option value=\"Iceland\"  class=\"choice-101 depth-1\"  >Iceland<\/option><option value=\"Bouvet Island\"  class=\"choice-102 depth-1\"  >Bouvet Island<\/option><option value=\"Isle of Man\"  class=\"choice-103 depth-1\"  >Isle of Man<\/option><option value=\"Christmas Island\"  class=\"choice-104 depth-1\"  >Christmas Island<\/option><option value=\"Island of Saint Barth\u00e9lemy\"  class=\"choice-105 depth-1\"  >Island of Saint Barth\u00e9lemy<\/option><option value=\"Aland Islands\"  class=\"choice-106 depth-1\"  >Aland Islands<\/option><option value=\"Cayman Islands\"  class=\"choice-107 depth-1\"  >Cayman Islands<\/option><option value=\"Cocos Islands (Keeling)\"  class=\"choice-108 depth-1\"  >Cocos Islands (Keeling)<\/option><option value=\"Cook Islands\"  class=\"choice-109 depth-1\"  >Cook Islands<\/option><option value=\"Falkland Islands (Malvinas)\"  class=\"choice-110 depth-1\"  >Falkland Islands (Malvinas)<\/option><option value=\"Faroe Islands\"  class=\"choice-111 depth-1\"  >Faroe Islands<\/option><option value=\"Heard and McDonald Islands\"  class=\"choice-112 depth-1\"  >Heard and McDonald Islands<\/option><option value=\"Northern Mariana Islands\"  class=\"choice-113 depth-1\"  >Northern Mariana Islands<\/option><option value=\"Marshall Islands\"  class=\"choice-114 depth-1\"  >Marshall Islands<\/option><option value=\"Norfolk Islands\"  class=\"choice-115 depth-1\"  >Norfolk Islands<\/option><option value=\"Saint Pierre and Miquelon Islands\"  class=\"choice-116 depth-1\"  >Saint Pierre and Miquelon Islands<\/option><option value=\"Solomon Islands\"  class=\"choice-117 depth-1\"  >Solomon Islands<\/option><option value=\"Svalbard and Jan Mayen Islands\"  class=\"choice-118 depth-1\"  >Svalbard and Jan Mayen Islands<\/option><option value=\"Turks and Caicos Islands\"  class=\"choice-119 depth-1\"  >Turks and Caicos Islands<\/option><option value=\"Virgin Islands (U.S.)\"  class=\"choice-120 depth-1\"  >Virgin Islands (U.S.)<\/option><option value=\"Virgin Islands (British)\"  class=\"choice-121 depth-1\"  >Virgin Islands (British)<\/option><option value=\"Minor outer islands of the United States of America\"  class=\"choice-122 depth-1\"  >Minor outer islands of the United States of America<\/option><option value=\"Israel\"  class=\"choice-123 depth-1\"  >Israel<\/option><option value=\"Italy\"  class=\"choice-124 depth-1\"  >Italy<\/option><option value=\"Kazakhstan\"  class=\"choice-125 depth-1\"  >Kazakhstan<\/option><option value=\"Kenya\"  class=\"choice-126 depth-1\"  >Kenya<\/option><option value=\"Kyrgyzstan\"  class=\"choice-127 depth-1\"  >Kyrgyzstan<\/option><option value=\"Kiribati\"  class=\"choice-128 depth-1\"  >Kiribati<\/option><option value=\"Korea (People&#039;s Democratic Republic of)\"  class=\"choice-129 depth-1\"  >Korea (People's Democratic Republic of)<\/option><option value=\"Korea (Republic of)\"  class=\"choice-130 depth-1\"  >Korea (Republic of)<\/option><option value=\"Kosovo\"  class=\"choice-131 depth-1\"  >Kosovo<\/option><option value=\"Kuwait\"  class=\"choice-132 depth-1\"  >Kuwait<\/option><option value=\"Lesotho\"  class=\"choice-133 depth-1\"  >Lesotho<\/option><option value=\"Latvia\"  class=\"choice-134 depth-1\"  >Latvia<\/option><option value=\"Lebanon\"  class=\"choice-135 depth-1\"  >Lebanon<\/option><option value=\"Liberia\"  class=\"choice-136 depth-1\"  >Liberia<\/option><option value=\"Libya\"  class=\"choice-137 depth-1\"  >Libya<\/option><option value=\"Liechtenstein\"  class=\"choice-138 depth-1\"  >Liechtenstein<\/option><option value=\"Lithuania\"  class=\"choice-139 depth-1\"  >Lithuania<\/option><option value=\"Luxembourg\"  class=\"choice-140 depth-1\"  >Luxembourg<\/option><option value=\"Macau\"  class=\"choice-141 depth-1\"  >Macau<\/option><option value=\"North Macedonia (Republic of)\"  class=\"choice-142 depth-1\"  >North Macedonia (Republic of)<\/option><option value=\"Madagascar\"  class=\"choice-143 depth-1\"  >Madagascar<\/option><option value=\"Jersey\"  class=\"choice-144 depth-1\"  >Jersey<\/option><option value=\"Malawi\"  class=\"choice-145 depth-1\"  >Malawi<\/option><option value=\"Maldives\"  class=\"choice-146 depth-1\"  >Maldives<\/option><option value=\"Malaysia\"  class=\"choice-147 depth-1\"  >Malaysia<\/option><option value=\"Mali\"  class=\"choice-148 depth-1\"  >Mali<\/option><option value=\"Malta\"  class=\"choice-149 depth-1\"  >Malta<\/option><option value=\"Morocco\"  class=\"choice-150 depth-1\"  >Morocco<\/option><option value=\"Martinique\"  class=\"choice-151 depth-1\"  >Martinique<\/option><option value=\"Mauritania\"  class=\"choice-152 depth-1\"  >Mauritania<\/option><option value=\"Mauritius\"  class=\"choice-153 depth-1\"  >Mauritius<\/option><option value=\"Mayotte\"  class=\"choice-154 depth-1\"  >Mayotte<\/option><option value=\"Mexico\"  class=\"choice-155 depth-1\"  >Mexico<\/option><option value=\"Micronesia (Confederation of States of)\"  class=\"choice-156 depth-1\"  >Micronesia (Confederation of States of)<\/option><option value=\"Moldova (Republic of)\"  class=\"choice-157 depth-1\"  >Moldova (Republic of)<\/option><option value=\"Monaco\"  class=\"choice-158 depth-1\"  >Monaco<\/option><option value=\"Mongolia\"  class=\"choice-159 depth-1\"  >Mongolia<\/option><option value=\"Montenegro\"  class=\"choice-160 depth-1\"  >Montenegro<\/option><option value=\"Montserrat\"  class=\"choice-161 depth-1\"  >Montserrat<\/option><option value=\"Mozambique\"  class=\"choice-162 depth-1\"  >Mozambique<\/option><option value=\"Namibia\"  class=\"choice-163 depth-1\"  >Namibia<\/option><option value=\"Nauru\"  class=\"choice-164 depth-1\"  >Nauru<\/option><option value=\"Nepal\"  class=\"choice-165 depth-1\"  >Nepal<\/option><option value=\"Nicaragua\"  class=\"choice-166 depth-1\"  >Nicaragua<\/option><option value=\"Niger\"  class=\"choice-167 depth-1\"  >Niger<\/option><option value=\"Nigeria\"  class=\"choice-168 depth-1\"  >Nigeria<\/option><option value=\"Niue\"  class=\"choice-169 depth-1\"  >Niue<\/option><option value=\"Norway\"  class=\"choice-170 depth-1\"  >Norway<\/option><option value=\"New Caledonia\"  class=\"choice-171 depth-1\"  >New Caledonia<\/option><option value=\"New Zealand\"  class=\"choice-172 depth-1\"  >New Zealand<\/option><option value=\"Oman\"  class=\"choice-173 depth-1\"  >Oman<\/option><option value=\"Netherlands\"  class=\"choice-174 depth-1\"  >Netherlands<\/option><option value=\"Pakistan\"  class=\"choice-175 depth-1\"  >Pakistan<\/option><option value=\"Palau\"  class=\"choice-176 depth-1\"  >Palau<\/option><option value=\"Palestine (State of)\"  class=\"choice-177 depth-1\"  >Palestine (State of)<\/option><option value=\"Panama\"  class=\"choice-178 depth-1\"  >Panama<\/option><option value=\"Papua New Guinea\"  class=\"choice-179 depth-1\"  >Papua New Guinea<\/option><option value=\"Paraguay\"  class=\"choice-180 depth-1\"  >Paraguay<\/option><option value=\"Peru\"  class=\"choice-181 depth-1\"  >Peru<\/option><option value=\"Pitcairn\"  class=\"choice-182 depth-1\"  >Pitcairn<\/option><option value=\"Poland\"  class=\"choice-183 depth-1\"  >Poland<\/option><option value=\"French Polynesia\"  class=\"choice-184 depth-1\"  >French Polynesia<\/option><option value=\"Puerto Rico\"  class=\"choice-185 depth-1\"  >Puerto Rico<\/option><option value=\"Portugal\"  class=\"choice-186 depth-1\"  >Portugal<\/option><option value=\"Qatar\"  class=\"choice-187 depth-1\"  >Qatar<\/option><option value=\"United Kingdom of Great Britain and Northern Ireland\"  class=\"choice-188 depth-1\"  >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"Arab Republic of Syria\"  class=\"choice-189 depth-1\"  >Arab Republic of Syria<\/option><option value=\"Czech Republic\"  class=\"choice-190 depth-1\"  >Czech Republic<\/option><option value=\"Central African Republic\"  class=\"choice-191 depth-1\"  >Central African Republic<\/option><option value=\"Lao People&#039;s Democratic Republic\"  class=\"choice-192 depth-1\"  >Lao People's Democratic Republic<\/option><option value=\"Dominican Republic\"  class=\"choice-193 depth-1\"  >Dominican Republic<\/option><option value=\"Reunion (Island of)\"  class=\"choice-194 depth-1\"  >Reunion (Island of)<\/option><option value=\"Romania\"  class=\"choice-195 depth-1\"  >Romania<\/option><option value=\"Rwanda\"  class=\"choice-196 depth-1\"  >Rwanda<\/option><option value=\"Western Sahara\"  class=\"choice-197 depth-1\"  >Western Sahara<\/option><option value=\"Saint Kitts and Nevis\"  class=\"choice-198 depth-1\"  >Saint Kitts and Nevis<\/option><option value=\"Saint Vincent and the Grenadines\"  class=\"choice-199 depth-1\"  >Saint Vincent and the Grenadines<\/option><option value=\"Saint-Martin (French Part)\"  class=\"choice-200 depth-1\"  >Saint-Martin (French Part)<\/option><option value=\"Samoa\"  class=\"choice-201 depth-1\"  >Samoa<\/option><option value=\"American Samoa\"  class=\"choice-202 depth-1\"  >American Samoa<\/option><option value=\"San Marino\"  class=\"choice-203 depth-1\"  >San Marino<\/option><option value=\"St. Helena, Ascension and Tristan da Cunha\"  class=\"choice-204 depth-1\"  >St. Helena, Ascension and Tristan da Cunha<\/option><option value=\"Saint Lucia\"  class=\"choice-205 depth-1\"  >Saint Lucia<\/option><option value=\"Sao Tome and Principe\"  class=\"choice-206 depth-1\"  >Sao Tome and Principe<\/option><option value=\"Senegal\"  class=\"choice-207 depth-1\"  >Senegal<\/option><option value=\"Serbia\"  class=\"choice-208 depth-1\"  >Serbia<\/option><option value=\"Seychelles\"  class=\"choice-209 depth-1\"  >Seychelles<\/option><option value=\"Sierra Leone\"  class=\"choice-210 depth-1\"  >Sierra Leone<\/option><option value=\"Singapore\"  class=\"choice-211 depth-1\"  >Singapore<\/option><option value=\"Sint Maarten (part of the Netherlands)\"  class=\"choice-212 depth-1\"  >Sint Maarten (part of the Netherlands)<\/option><option value=\"Slovakia\"  class=\"choice-213 depth-1\"  >Slovakia<\/option><option value=\"Slovenia\"  class=\"choice-214 depth-1\"  >Slovenia<\/option><option value=\"Somalia\"  class=\"choice-215 depth-1\"  >Somalia<\/option><option value=\"Spain\"  class=\"choice-216 depth-1\"  >Spain<\/option><option value=\"Sri Lanka\"  class=\"choice-217 depth-1\"  >Sri Lanka<\/option><option value=\"United States of America\"  class=\"choice-218 depth-1\"  >United States of America<\/option><option value=\"Vatican City State\"  class=\"choice-219 depth-1\"  >Vatican City State<\/option><option value=\"South Africa\"  class=\"choice-220 depth-1\"  >South Africa<\/option><option value=\"Sudan\"  class=\"choice-221 depth-1\"  >Sudan<\/option><option value=\"South Sudan\"  class=\"choice-222 depth-1\"  >South Sudan<\/option><option value=\"Suriname\"  class=\"choice-223 depth-1\"  >Suriname<\/option><option value=\"Sweden\"  class=\"choice-224 depth-1\"  >Sweden<\/option><option value=\"Switzerland\"  selected='selected' class=\"choice-225 depth-1\"  >Switzerland<\/option><option value=\"Tajikistan\"  class=\"choice-226 depth-1\"  >Tajikistan<\/option><option value=\"Taiwan, Republic of China\"  class=\"choice-227 depth-1\"  >Taiwan, Republic of China<\/option><option value=\"Tanzania (United Republic of)\"  class=\"choice-228 depth-1\"  >Tanzania (United Republic of)<\/option><option value=\"French Southern Territories\"  class=\"choice-229 depth-1\"  >French Southern Territories<\/option><option value=\"British territory in the Indian Ocean\"  class=\"choice-230 depth-1\"  >British territory in the Indian Ocean<\/option><option value=\"Thailand\"  class=\"choice-231 depth-1\"  >Thailand<\/option><option value=\"East Timor\"  class=\"choice-232 depth-1\"  >East Timor<\/option><option value=\"Togo\"  class=\"choice-233 depth-1\"  >Togo<\/option><option value=\"Tokelau\"  class=\"choice-234 depth-1\"  >Tokelau<\/option><option value=\"Tonga\"  class=\"choice-235 depth-1\"  >Tonga<\/option><option value=\"Trinidad and Tobago\"  class=\"choice-236 depth-1\"  >Trinidad and Tobago<\/option><option value=\"Tunisia\"  class=\"choice-237 depth-1\"  >Tunisia<\/option><option value=\"Turkey\"  class=\"choice-238 depth-1\"  >Turkey<\/option><option value=\"Turkmenistan\"  class=\"choice-239 depth-1\"  >Turkmenistan<\/option><option value=\"Tuvalu\"  class=\"choice-240 depth-1\"  >Tuvalu<\/option><option value=\"Ukraine\"  class=\"choice-241 depth-1\"  >Ukraine<\/option><option value=\"Uganda\"  class=\"choice-242 depth-1\"  >Uganda<\/option><option value=\"Hungary\"  class=\"choice-243 depth-1\"  >Hungary<\/option><option value=\"Uruguay\"  class=\"choice-244 depth-1\"  >Uruguay<\/option><option value=\"Uzbekistan\"  class=\"choice-245 depth-1\"  >Uzbekistan<\/option><option value=\"Vanuatu\"  class=\"choice-246 depth-1\"  >Vanuatu<\/option><option value=\"Venezuela (Bollivian Republic of)\"  class=\"choice-247 depth-1\"  >Venezuela (Bollivian Republic of)<\/option><option value=\"Vietnam\"  class=\"choice-248 depth-1\"  >Vietnam<\/option><option value=\"Wallis and Futuna\"  class=\"choice-249 depth-1\"  >Wallis and Futuna<\/option><option value=\"Yemen\"  class=\"choice-250 depth-1\"  >Yemen<\/option><option value=\"Zambia\"  class=\"choice-251 depth-1\"  >Zambia<\/option><option value=\"Zimbabwe\"  class=\"choice-252 depth-1\"  >Zimbabwe<\/option><option value=\"eSwatini (Kingdom of)\"  class=\"choice-253 depth-1\"  >eSwatini (Kingdom of)<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_17-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"17\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_17\">Address Referent<\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-58-field_17\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][17][address1]\" placeholder=\"Address\" ><label for=\"wpforms-58-field_17\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-58-field_17-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][17][city]\" placeholder=\"City\" ><label for=\"wpforms-58-field_17-city\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-58-field_17-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][17][state]\" placeholder=\"Canton\" ><label for=\"wpforms-58-field_17-state\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">State \/ Province \/ Region<\/label><\/div><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_18-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"18\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_18\">Phone<\/label><input type=\"tel\" id=\"wpforms-58-field_18\" class=\"wpforms-field-large\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][18]\" placeholder=\"Phone\" aria-label=\"Phone\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_19-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"19\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_19\">Email<\/label><input type=\"email\" id=\"wpforms-58-field_19\" class=\"wpforms-field-large\" name=\"wpforms[fields][19]\" placeholder=\"Email\" spellcheck=\"false\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_83-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"83\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tReason for contact\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_84-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"84\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_84\">Main diagnosis<\/label><input type=\"text\" id=\"wpforms-58-field_84\" class=\"wpforms-field-large\" name=\"wpforms[fields][84]\" placeholder=\"Specific principal diagnosis\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_87-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"87\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_87\">Specific secondary diagnoses  <\/label><input type=\"text\" id=\"wpforms-58-field_87\" class=\"wpforms-field-large\" name=\"wpforms[fields][87]\" placeholder=\"Secondary diagnoses critical to intake\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_85-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"85\" style=\"display:none;\"><label class=\"wpforms-field-label\">Benefits required<\/label><ul id=\"wpforms-58-field_85\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_1\" name=\"wpforms[fields][85][]\" value=\"Welfare benefits basic care\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_1\">Welfare benefits basic care<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_2\" name=\"wpforms[fields][85][]\" value=\"Nursing services\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_2\">Nursing services<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_4\" name=\"wpforms[fields][85][]\" value=\"Specialized nursing services\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_4\">Specialized nursing services<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_7\" name=\"wpforms[fields][85][]\" value=\"Private benefits\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_7\">Private benefits<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_6\" name=\"wpforms[fields][85][]\" value=\"International performance\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_6\">International performance<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_9\" name=\"wpforms[fields][85][]\" value=\"Telemedicine service\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_9\">Telemedicine service<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_8\" name=\"wpforms[fields][85][]\" value=\"Telecare service\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_8\">Telecare service<\/label><\/li><\/ul><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_88-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"88\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_88\">Amount of interventions required<\/label><input type=\"text\" id=\"wpforms-58-field_88\" class=\"wpforms-field-large\" name=\"wpforms[fields][88]\" placeholder=\"Specific quantity of interventions\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_86-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"86\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_86\">Request for initiation of intake<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_86\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"0\" data-input=\"true\" name=\"wpforms[fields][86][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_24-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"24\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tDegree of priority\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_30-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"30\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\">degree of priority <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_30\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_30_1\" name=\"wpforms[fields][30]\" value=\"Low\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_30_1\">Low<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_30_2\" name=\"wpforms[fields][30]\" value=\"Medium\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_30_2\">Medium<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_30_3\" name=\"wpforms[fields][30]\" value=\"High\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_30_3\">High<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_30_4\" name=\"wpforms[fields][30]\" value=\"Request for in-depth information about the service\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_30_4\">Request for in-depth information about the service<\/label><\/li><\/ul><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_28-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"28\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_28\">Additional text - priority grade<\/label><textarea id=\"wpforms-58-field_28\" class=\"wpforms-field-medium\" name=\"wpforms[fields][28]\" placeholder=\"Additional text\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_37-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"37\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tFill in the following fields:\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_38-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"38\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_38\">Name of requesting facility <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_38\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][38]\" placeholder=\"Enter name of requesting facility\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_39-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"39\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_39\">Contact person of the requesting facility and respective function <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_39\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][39]\" placeholder=\"Enter contact name\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_104-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"104\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_104\">Address <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_104\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][104]\" placeholder=\"Enter an address\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_41-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"41\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tPatient data\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_42-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"42\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_42\">first name last name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_42\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][42]\" placeholder=\"First and Last Name\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_43-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"43\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_43\">Date of birth <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_43\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][43][date]\" placeholder=\"Date of birth\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_108-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"108\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_108\">Country Patient<\/label><select id=\"wpforms-58-field_108\" class=\"wpforms-field-large\" name=\"wpforms[fields][108]\"><option value=\"\" class=\"placeholder\" disabled >Nation<\/option><option value=\"Afghanistan\"  class=\"choice-4 depth-1\"  >Afghanistan<\/option><option value=\"Albania\"  class=\"choice-5 depth-1\"  >Albania<\/option><option value=\"Algeria\"  class=\"choice-6 depth-1\"  >Algeria<\/option><option value=\"Andorra\"  class=\"choice-7 depth-1\"  >Andorra<\/option><option value=\"Angola\"  class=\"choice-8 depth-1\"  >Angola<\/option><option value=\"Eel\"  class=\"choice-9 depth-1\"  >Eel<\/option><option value=\"Antarctica\"  class=\"choice-10 depth-1\"  >Antarctica<\/option><option value=\"Antigua and Barbuda\"  class=\"choice-11 depth-1\"  >Antigua and Barbuda<\/option><option value=\"Saudi Arabia\"  class=\"choice-12 depth-1\"  >Saudi Arabia<\/option><option value=\"Argentina\"  class=\"choice-13 depth-1\"  >Argentina<\/option><option value=\"Armenia\"  class=\"choice-14 depth-1\"  >Armenia<\/option><option value=\"Aruba\"  class=\"choice-15 depth-1\"  >Aruba<\/option><option value=\"Australia\"  class=\"choice-16 depth-1\"  >Australia<\/option><option value=\"Austria\"  class=\"choice-17 depth-1\"  >Austria<\/option><option value=\"Azerbaijan\"  class=\"choice-18 depth-1\"  >Azerbaijan<\/option><option value=\"Bahamas\"  class=\"choice-19 depth-1\"  >Bahamas<\/option><option value=\"Bahrain\"  class=\"choice-20 depth-1\"  >Bahrain<\/option><option value=\"Bangladesh\"  class=\"choice-21 depth-1\"  >Bangladesh<\/option><option value=\"Barbados\"  class=\"choice-22 depth-1\"  >Barbados<\/option><option value=\"Belgium\"  class=\"choice-23 depth-1\"  >Belgium<\/option><option value=\"Belize\"  class=\"choice-24 depth-1\"  >Belize<\/option><option value=\"Benin\"  class=\"choice-25 depth-1\"  >Benin<\/option><option value=\"Bermuda\"  class=\"choice-26 depth-1\"  >Bermuda<\/option><option value=\"Bhutan\"  class=\"choice-27 depth-1\"  >Bhutan<\/option><option value=\"Belarus\"  class=\"choice-28 depth-1\"  >Belarus<\/option><option value=\"Burma\"  class=\"choice-29 depth-1\"  >Burma<\/option><option value=\"Bolivia (plurinational state of)\"  class=\"choice-30 depth-1\"  >Bolivia (plurinational state of)<\/option><option value=\"Bonaire, Saint Eustatius and Saba\"  class=\"choice-31 depth-1\"  >Bonaire, Saint Eustatius and Saba<\/option><option value=\"Bosnia-Herzegovina\"  class=\"choice-32 depth-1\"  >Bosnia-Herzegovina<\/option><option value=\"Botswana\"  class=\"choice-33 depth-1\"  >Botswana<\/option><option value=\"Brazil\"  class=\"choice-34 depth-1\"  >Brazil<\/option><option value=\"Brunei Darrussalam\"  class=\"choice-35 depth-1\"  >Brunei Darrussalam<\/option><option value=\"Bulgaria\"  class=\"choice-36 depth-1\"  >Bulgaria<\/option><option value=\"Burkina Faso\"  class=\"choice-37 depth-1\"  >Burkina Faso<\/option><option value=\"Burundi\"  class=\"choice-38 depth-1\"  >Burundi<\/option><option value=\"Cambodia\"  class=\"choice-39 depth-1\"  >Cambodia<\/option><option value=\"Cameroon\"  class=\"choice-40 depth-1\"  >Cameroon<\/option><option value=\"Canada\"  class=\"choice-41 depth-1\"  >Canada<\/option><option value=\"Cape Verde\"  class=\"choice-42 depth-1\"  >Cape Verde<\/option><option value=\"Chad\"  class=\"choice-43 depth-1\"  >Chad<\/option><option value=\"Chile\"  class=\"choice-44 depth-1\"  >Chile<\/option><option value=\"China\"  class=\"choice-45 depth-1\"  >China<\/option><option value=\"Cyprus\"  class=\"choice-46 depth-1\"  >Cyprus<\/option><option value=\"Colombia\"  class=\"choice-47 depth-1\"  >Colombia<\/option><option value=\"Comoros\"  class=\"choice-48 depth-1\"  >Comoros<\/option><option value=\"Congo\"  class=\"choice-49 depth-1\"  >Congo<\/option><option value=\"Congo (Democratic Republic of the)\"  class=\"choice-50 depth-1\"  >Congo (Democratic Republic of the)<\/option><option value=\"Costa Rica\"  class=\"choice-51 depth-1\"  >Costa Rica<\/option><option value=\"Ivory Coast\"  class=\"choice-52 depth-1\"  >Ivory Coast<\/option><option value=\"Croatia\"  class=\"choice-53 depth-1\"  >Croatia<\/option><option value=\"Cuba\"  class=\"choice-54 depth-1\"  >Cuba<\/option><option value=\"Cura\u00e7ao\"  class=\"choice-55 depth-1\"  >Cura\u00e7ao<\/option><option value=\"Denmark\"  class=\"choice-56 depth-1\"  >Denmark<\/option><option value=\"Dominica\"  class=\"choice-57 depth-1\"  >Dominica<\/option><option value=\"Ecuador\"  class=\"choice-58 depth-1\"  >Ecuador<\/option><option value=\"Egypt\"  class=\"choice-59 depth-1\"  >Egypt<\/option><option value=\"El Salvador\"  class=\"choice-60 depth-1\"  >El Salvador<\/option><option value=\"United Arab Emirates\"  class=\"choice-61 depth-1\"  >United Arab Emirates<\/option><option value=\"Eritrea\"  class=\"choice-62 depth-1\"  >Eritrea<\/option><option value=\"Estonia\"  class=\"choice-63 depth-1\"  >Estonia<\/option><option value=\"Ethiopia\"  class=\"choice-64 depth-1\"  >Ethiopia<\/option><option value=\"Russian Federation\"  class=\"choice-65 depth-1\"  >Russian Federation<\/option><option value=\"Fiji\"  class=\"choice-66 depth-1\"  >Fiji<\/option><option value=\"Philippines\"  class=\"choice-67 depth-1\"  >Philippines<\/option><option value=\"Finland\"  class=\"choice-68 depth-1\"  >Finland<\/option><option value=\"France\"  class=\"choice-69 depth-1\"  >France<\/option><option value=\"Gabon\"  class=\"choice-70 depth-1\"  >Gabon<\/option><option value=\"Gambia\"  class=\"choice-71 depth-1\"  >Gambia<\/option><option value=\"Georgia\"  class=\"choice-72 depth-1\"  >Georgia<\/option><option value=\"South Georgia and the South Sandwich Islands\"  class=\"choice-73 depth-1\"  >South Georgia and the South Sandwich Islands<\/option><option value=\"Germany\"  class=\"choice-74 depth-1\"  >Germany<\/option><option value=\"Ghana\"  class=\"choice-75 depth-1\"  >Ghana<\/option><option value=\"Jamaica\"  class=\"choice-76 depth-1\"  >Jamaica<\/option><option value=\"Japan\"  class=\"choice-77 depth-1\"  >Japan<\/option><option value=\"Gibraltar\"  class=\"choice-78 depth-1\"  >Gibraltar<\/option><option value=\"Djibouti\"  class=\"choice-79 depth-1\"  >Djibouti<\/option><option value=\"Jordan\"  class=\"choice-80 depth-1\"  >Jordan<\/option><option value=\"Greece\"  class=\"choice-81 depth-1\"  >Greece<\/option><option value=\"Grenada\"  class=\"choice-82 depth-1\"  >Grenada<\/option><option value=\"Greenland\"  class=\"choice-83 depth-1\"  >Greenland<\/option><option value=\"Guadeloupe\"  class=\"choice-84 depth-1\"  >Guadeloupe<\/option><option value=\"Guam\"  class=\"choice-85 depth-1\"  >Guam<\/option><option value=\"Guatemala\"  class=\"choice-86 depth-1\"  >Guatemala<\/option><option value=\"Guernsey\"  class=\"choice-87 depth-1\"  >Guernsey<\/option><option value=\"French Guiana\"  class=\"choice-88 depth-1\"  >French Guiana<\/option><option value=\"Guinea\"  class=\"choice-89 depth-1\"  >Guinea<\/option><option value=\"Equatorial Guinea\"  class=\"choice-90 depth-1\"  >Equatorial Guinea<\/option><option value=\"Guinea-Bissau\"  class=\"choice-91 depth-1\"  >Guinea-Bissau<\/option><option value=\"Guyana\"  class=\"choice-92 depth-1\"  >Guyana<\/option><option value=\"Haiti\"  class=\"choice-93 depth-1\"  >Haiti<\/option><option value=\"Honduras\"  class=\"choice-94 depth-1\"  >Honduras<\/option><option value=\"Hong Kong\"  class=\"choice-95 depth-1\"  >Hong Kong<\/option><option value=\"India\"  class=\"choice-96 depth-1\"  >India<\/option><option value=\"Indonesia\"  class=\"choice-97 depth-1\"  >Indonesia<\/option><option value=\"Iran (Islamic Republic of)\"  class=\"choice-98 depth-1\"  >Iran (Islamic Republic of)<\/option><option value=\"Iraq\"  class=\"choice-99 depth-1\"  >Iraq<\/option><option value=\"Ireland (Republic of)\"  class=\"choice-100 depth-1\"  >Ireland (Republic of)<\/option><option value=\"Iceland\"  class=\"choice-101 depth-1\"  >Iceland<\/option><option value=\"Bouvet Island\"  class=\"choice-102 depth-1\"  >Bouvet Island<\/option><option value=\"Isle of Man\"  class=\"choice-103 depth-1\"  >Isle of Man<\/option><option value=\"Christmas Island\"  class=\"choice-104 depth-1\"  >Christmas Island<\/option><option value=\"Island of Saint Barth\u00e9lemy\"  class=\"choice-105 depth-1\"  >Island of Saint Barth\u00e9lemy<\/option><option value=\"Aland Islands\"  class=\"choice-106 depth-1\"  >Aland Islands<\/option><option value=\"Cayman Islands\"  class=\"choice-107 depth-1\"  >Cayman Islands<\/option><option value=\"Cocos Islands (Keeling)\"  class=\"choice-108 depth-1\"  >Cocos Islands (Keeling)<\/option><option value=\"Cook Islands\"  class=\"choice-109 depth-1\"  >Cook Islands<\/option><option value=\"Falkland Islands (Malvinas)\"  class=\"choice-110 depth-1\"  >Falkland Islands (Malvinas)<\/option><option value=\"Faroe Islands\"  class=\"choice-111 depth-1\"  >Faroe Islands<\/option><option value=\"Heard and McDonald Islands\"  class=\"choice-112 depth-1\"  >Heard and McDonald Islands<\/option><option value=\"Northern Mariana Islands\"  class=\"choice-113 depth-1\"  >Northern Mariana Islands<\/option><option value=\"Marshall Islands\"  class=\"choice-114 depth-1\"  >Marshall Islands<\/option><option value=\"Norfolk Islands\"  class=\"choice-115 depth-1\"  >Norfolk Islands<\/option><option value=\"Saint Pierre and Miquelon Islands\"  class=\"choice-116 depth-1\"  >Saint Pierre and Miquelon Islands<\/option><option value=\"Solomon Islands\"  class=\"choice-117 depth-1\"  >Solomon Islands<\/option><option value=\"Svalbard and Jan Mayen Islands\"  class=\"choice-118 depth-1\"  >Svalbard and Jan Mayen Islands<\/option><option value=\"Turks and Caicos Islands\"  class=\"choice-119 depth-1\"  >Turks and Caicos Islands<\/option><option value=\"Virgin Islands (U.S.)\"  class=\"choice-120 depth-1\"  >Virgin Islands (U.S.)<\/option><option value=\"Virgin Islands (British)\"  class=\"choice-121 depth-1\"  >Virgin Islands (British)<\/option><option value=\"Minor outer islands of the United States of America\"  class=\"choice-122 depth-1\"  >Minor outer islands of the United States of America<\/option><option value=\"Israel\"  class=\"choice-123 depth-1\"  >Israel<\/option><option value=\"Italy\"  class=\"choice-124 depth-1\"  >Italy<\/option><option value=\"Kazakhstan\"  class=\"choice-125 depth-1\"  >Kazakhstan<\/option><option value=\"Kenya\"  class=\"choice-126 depth-1\"  >Kenya<\/option><option value=\"Kyrgyzstan\"  class=\"choice-127 depth-1\"  >Kyrgyzstan<\/option><option value=\"Kiribati\"  class=\"choice-128 depth-1\"  >Kiribati<\/option><option value=\"Korea (People&#039;s Democratic Republic of)\"  class=\"choice-129 depth-1\"  >Korea (People's Democratic Republic of)<\/option><option value=\"Korea (Republic of)\"  class=\"choice-130 depth-1\"  >Korea (Republic of)<\/option><option value=\"Kosovo\"  class=\"choice-131 depth-1\"  >Kosovo<\/option><option value=\"Kuwait\"  class=\"choice-132 depth-1\"  >Kuwait<\/option><option value=\"Lesotho\"  class=\"choice-133 depth-1\"  >Lesotho<\/option><option value=\"Latvia\"  class=\"choice-134 depth-1\"  >Latvia<\/option><option value=\"Lebanon\"  class=\"choice-135 depth-1\"  >Lebanon<\/option><option value=\"Liberia\"  class=\"choice-136 depth-1\"  >Liberia<\/option><option value=\"Libya\"  class=\"choice-137 depth-1\"  >Libya<\/option><option value=\"Liechtenstein\"  class=\"choice-138 depth-1\"  >Liechtenstein<\/option><option value=\"Lithuania\"  class=\"choice-139 depth-1\"  >Lithuania<\/option><option value=\"Luxembourg\"  class=\"choice-140 depth-1\"  >Luxembourg<\/option><option value=\"Macau\"  class=\"choice-141 depth-1\"  >Macau<\/option><option value=\"North Macedonia (Republic of)\"  class=\"choice-142 depth-1\"  >North Macedonia (Republic of)<\/option><option value=\"Madagascar\"  class=\"choice-143 depth-1\"  >Madagascar<\/option><option value=\"Jersey\"  class=\"choice-144 depth-1\"  >Jersey<\/option><option value=\"Malawi\"  class=\"choice-145 depth-1\"  >Malawi<\/option><option value=\"Maldives\"  class=\"choice-146 depth-1\"  >Maldives<\/option><option value=\"Malaysia\"  class=\"choice-147 depth-1\"  >Malaysia<\/option><option value=\"Mali\"  class=\"choice-148 depth-1\"  >Mali<\/option><option value=\"Malta\"  class=\"choice-149 depth-1\"  >Malta<\/option><option value=\"Morocco\"  class=\"choice-150 depth-1\"  >Morocco<\/option><option value=\"Martinique\"  class=\"choice-151 depth-1\"  >Martinique<\/option><option value=\"Mauritania\"  class=\"choice-152 depth-1\"  >Mauritania<\/option><option value=\"Mauritius\"  class=\"choice-153 depth-1\"  >Mauritius<\/option><option value=\"Mayotte\"  class=\"choice-154 depth-1\"  >Mayotte<\/option><option value=\"Mexico\"  class=\"choice-155 depth-1\"  >Mexico<\/option><option value=\"Micronesia (Confederation of States of)\"  class=\"choice-156 depth-1\"  >Micronesia (Confederation of States of)<\/option><option value=\"Moldova (Republic of)\"  class=\"choice-157 depth-1\"  >Moldova (Republic of)<\/option><option value=\"Monaco\"  class=\"choice-158 depth-1\"  >Monaco<\/option><option value=\"Mongolia\"  class=\"choice-159 depth-1\"  >Mongolia<\/option><option value=\"Montenegro\"  class=\"choice-160 depth-1\"  >Montenegro<\/option><option value=\"Montserrat\"  class=\"choice-161 depth-1\"  >Montserrat<\/option><option value=\"Mozambique\"  class=\"choice-162 depth-1\"  >Mozambique<\/option><option value=\"Namibia\"  class=\"choice-163 depth-1\"  >Namibia<\/option><option value=\"Nauru\"  class=\"choice-164 depth-1\"  >Nauru<\/option><option value=\"Nepal\"  class=\"choice-165 depth-1\"  >Nepal<\/option><option value=\"Nicaragua\"  class=\"choice-166 depth-1\"  >Nicaragua<\/option><option value=\"Niger\"  class=\"choice-167 depth-1\"  >Niger<\/option><option value=\"Nigeria\"  class=\"choice-168 depth-1\"  >Nigeria<\/option><option value=\"Niue\"  class=\"choice-169 depth-1\"  >Niue<\/option><option value=\"Norway\"  class=\"choice-170 depth-1\"  >Norway<\/option><option value=\"New Caledonia\"  class=\"choice-171 depth-1\"  >New Caledonia<\/option><option value=\"New Zealand\"  class=\"choice-172 depth-1\"  >New Zealand<\/option><option value=\"Oman\"  class=\"choice-173 depth-1\"  >Oman<\/option><option value=\"Netherlands\"  class=\"choice-174 depth-1\"  >Netherlands<\/option><option value=\"Pakistan\"  class=\"choice-175 depth-1\"  >Pakistan<\/option><option value=\"Palau\"  class=\"choice-176 depth-1\"  >Palau<\/option><option value=\"Palestine (State of)\"  class=\"choice-177 depth-1\"  >Palestine (State of)<\/option><option value=\"Panama\"  class=\"choice-178 depth-1\"  >Panama<\/option><option value=\"Papua New Guinea\"  class=\"choice-179 depth-1\"  >Papua New Guinea<\/option><option value=\"Paraguay\"  class=\"choice-180 depth-1\"  >Paraguay<\/option><option value=\"Peru\"  class=\"choice-181 depth-1\"  >Peru<\/option><option value=\"Pitcairn\"  class=\"choice-182 depth-1\"  >Pitcairn<\/option><option value=\"Poland\"  class=\"choice-183 depth-1\"  >Poland<\/option><option value=\"French Polynesia\"  class=\"choice-184 depth-1\"  >French Polynesia<\/option><option value=\"Puerto Rico\"  class=\"choice-185 depth-1\"  >Puerto Rico<\/option><option value=\"Portugal\"  class=\"choice-186 depth-1\"  >Portugal<\/option><option value=\"Qatar\"  class=\"choice-187 depth-1\"  >Qatar<\/option><option value=\"United Kingdom of Great Britain and Northern Ireland\"  class=\"choice-188 depth-1\"  >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"Arab Republic of Syria\"  class=\"choice-189 depth-1\"  >Arab Republic of Syria<\/option><option value=\"Czech Republic\"  class=\"choice-190 depth-1\"  >Czech Republic<\/option><option value=\"Central African Republic\"  class=\"choice-191 depth-1\"  >Central African Republic<\/option><option value=\"Lao People&#039;s Democratic Republic\"  class=\"choice-192 depth-1\"  >Lao People's Democratic Republic<\/option><option value=\"Dominican Republic\"  class=\"choice-193 depth-1\"  >Dominican Republic<\/option><option value=\"Reunion (Island of)\"  class=\"choice-194 depth-1\"  >Reunion (Island of)<\/option><option value=\"Romania\"  class=\"choice-195 depth-1\"  >Romania<\/option><option value=\"Rwanda\"  class=\"choice-196 depth-1\"  >Rwanda<\/option><option value=\"Western Sahara\"  class=\"choice-197 depth-1\"  >Western Sahara<\/option><option value=\"Saint Kitts and Nevis\"  class=\"choice-198 depth-1\"  >Saint Kitts and Nevis<\/option><option value=\"Saint Vincent and the Grenadines\"  class=\"choice-199 depth-1\"  >Saint Vincent and the Grenadines<\/option><option value=\"Saint-Martin (French Part)\"  class=\"choice-200 depth-1\"  >Saint-Martin (French Part)<\/option><option value=\"Samoa\"  class=\"choice-201 depth-1\"  >Samoa<\/option><option value=\"American Samoa\"  class=\"choice-202 depth-1\"  >American Samoa<\/option><option value=\"San Marino\"  class=\"choice-203 depth-1\"  >San Marino<\/option><option value=\"St. Helena, Ascension and Tristan da Cunha\"  class=\"choice-204 depth-1\"  >St. Helena, Ascension and Tristan da Cunha<\/option><option value=\"Saint Lucia\"  class=\"choice-205 depth-1\"  >Saint Lucia<\/option><option value=\"Sao Tome and Principe\"  class=\"choice-206 depth-1\"  >Sao Tome and Principe<\/option><option value=\"Senegal\"  class=\"choice-207 depth-1\"  >Senegal<\/option><option value=\"Serbia\"  class=\"choice-208 depth-1\"  >Serbia<\/option><option value=\"Seychelles\"  class=\"choice-209 depth-1\"  >Seychelles<\/option><option value=\"Sierra Leone\"  class=\"choice-210 depth-1\"  >Sierra Leone<\/option><option value=\"Singapore\"  class=\"choice-211 depth-1\"  >Singapore<\/option><option value=\"Sint Maarten (part of the Netherlands)\"  class=\"choice-212 depth-1\"  >Sint Maarten (part of the Netherlands)<\/option><option value=\"Slovakia\"  class=\"choice-213 depth-1\"  >Slovakia<\/option><option value=\"Slovenia\"  class=\"choice-214 depth-1\"  >Slovenia<\/option><option value=\"Somalia\"  class=\"choice-215 depth-1\"  >Somalia<\/option><option value=\"Spain\"  class=\"choice-216 depth-1\"  >Spain<\/option><option value=\"Sri Lanka\"  class=\"choice-217 depth-1\"  >Sri Lanka<\/option><option value=\"United States of America\"  class=\"choice-218 depth-1\"  >United States of America<\/option><option value=\"Vatican City State\"  class=\"choice-219 depth-1\"  >Vatican City State<\/option><option value=\"South Africa\"  class=\"choice-220 depth-1\"  >South Africa<\/option><option value=\"Sudan\"  class=\"choice-221 depth-1\"  >Sudan<\/option><option value=\"South Sudan\"  class=\"choice-222 depth-1\"  >South Sudan<\/option><option value=\"Suriname\"  class=\"choice-223 depth-1\"  >Suriname<\/option><option value=\"Sweden\"  class=\"choice-224 depth-1\"  >Sweden<\/option><option value=\"Switzerland\"  selected='selected' class=\"choice-225 depth-1\"  >Switzerland<\/option><option value=\"Tajikistan\"  class=\"choice-226 depth-1\"  >Tajikistan<\/option><option value=\"Taiwan, Republic of China\"  class=\"choice-227 depth-1\"  >Taiwan, Republic of China<\/option><option value=\"Tanzania (United Republic of)\"  class=\"choice-228 depth-1\"  >Tanzania (United Republic of)<\/option><option value=\"French Southern Territories\"  class=\"choice-229 depth-1\"  >French Southern Territories<\/option><option value=\"British territory in the Indian Ocean\"  class=\"choice-230 depth-1\"  >British territory in the Indian Ocean<\/option><option value=\"Thailand\"  class=\"choice-231 depth-1\"  >Thailand<\/option><option value=\"East Timor\"  class=\"choice-232 depth-1\"  >East Timor<\/option><option value=\"Togo\"  class=\"choice-233 depth-1\"  >Togo<\/option><option value=\"Tokelau\"  class=\"choice-234 depth-1\"  >Tokelau<\/option><option value=\"Tonga\"  class=\"choice-235 depth-1\"  >Tonga<\/option><option value=\"Trinidad and Tobago\"  class=\"choice-236 depth-1\"  >Trinidad and Tobago<\/option><option value=\"Tunisia\"  class=\"choice-237 depth-1\"  >Tunisia<\/option><option value=\"Turkey\"  class=\"choice-238 depth-1\"  >Turkey<\/option><option value=\"Turkmenistan\"  class=\"choice-239 depth-1\"  >Turkmenistan<\/option><option value=\"Tuvalu\"  class=\"choice-240 depth-1\"  >Tuvalu<\/option><option value=\"Ukraine\"  class=\"choice-241 depth-1\"  >Ukraine<\/option><option value=\"Uganda\"  class=\"choice-242 depth-1\"  >Uganda<\/option><option value=\"Hungary\"  class=\"choice-243 depth-1\"  >Hungary<\/option><option value=\"Uruguay\"  class=\"choice-244 depth-1\"  >Uruguay<\/option><option value=\"Uzbekistan\"  class=\"choice-245 depth-1\"  >Uzbekistan<\/option><option value=\"Vanuatu\"  class=\"choice-246 depth-1\"  >Vanuatu<\/option><option value=\"Venezuela (Bollivian Republic of)\"  class=\"choice-247 depth-1\"  >Venezuela (Bollivian Republic of)<\/option><option value=\"Vietnam\"  class=\"choice-248 depth-1\"  >Vietnam<\/option><option value=\"Wallis and Futuna\"  class=\"choice-249 depth-1\"  >Wallis and Futuna<\/option><option value=\"Yemen\"  class=\"choice-250 depth-1\"  >Yemen<\/option><option value=\"Zambia\"  class=\"choice-251 depth-1\"  >Zambia<\/option><option value=\"Zimbabwe\"  class=\"choice-252 depth-1\"  >Zimbabwe<\/option><option value=\"eSwatini (Kingdom of)\"  class=\"choice-253 depth-1\"  >eSwatini (Kingdom of)<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_44-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"44\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_44\">Address <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-58-field_44\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][44][address1]\" placeholder=\"Address\" required><label for=\"wpforms-58-field_44\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-58-field_44-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][44][city]\" placeholder=\"City\" required><label for=\"wpforms-58-field_44-city\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-58-field_44-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][44][state]\" placeholder=\"Canton\" required><label for=\"wpforms-58-field_44-state\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">State \/ Province \/ Region<\/label><\/div><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_45-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"45\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_45\">Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-58-field_45\" class=\"wpforms-field-large wpforms-field-required\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][45]\" placeholder=\"Phone\" aria-label=\"Phone\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_46-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"46\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_46\">Email<\/label><input type=\"email\" id=\"wpforms-58-field_46\" class=\"wpforms-field-large\" name=\"wpforms[fields][46]\" placeholder=\"Email\" spellcheck=\"false\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_48-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"48\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_48\">Attending physician <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_48\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][48]\" placeholder=\"Attending physician\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_95-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"95\" style=\"display:none;\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-58-field_96-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"96\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_96\">Insurance company<\/label><input type=\"text\" id=\"wpforms-58-field_96\" class=\"wpforms-field-large\" name=\"wpforms[fields][96]\" placeholder=\"Insurance company\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-58-field_97-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"97\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_97\">AVS<\/label><input type=\"text\" id=\"wpforms-58-field_97\" class=\"wpforms-field-large\" name=\"wpforms[fields][97]\" placeholder=\"AVS\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-58-field_49-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"49\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_49\">Insured Number<\/label><input type=\"text\" id=\"wpforms-58-field_49\" class=\"wpforms-field-large\" name=\"wpforms[fields][49]\" placeholder=\"Insured Number\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_89-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"89\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tReason for contact\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_90-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"90\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_90\">Main diagnosis <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_90\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][90]\" placeholder=\"Specific principal diagnosis\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_93-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"93\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_93\">Specific secondary diagnoses  <\/label><input type=\"text\" id=\"wpforms-58-field_93\" class=\"wpforms-field-large\" name=\"wpforms[fields][93]\" placeholder=\"Secondary diagnoses critical to intake\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_91-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"91\" style=\"display:none;\"><label class=\"wpforms-field-label\">Benefits required <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_91\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_1\" name=\"wpforms[fields][91][]\" value=\"Welfare benefits basic care\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_1\">Welfare benefits basic care<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_2\" name=\"wpforms[fields][91][]\" value=\"Nursing services\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_2\">Nursing services<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_4\" name=\"wpforms[fields][91][]\" value=\"Specialized nursing services\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_4\">Specialized nursing services<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_7\" name=\"wpforms[fields][91][]\" value=\"Private benefits\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_7\">Private benefits<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_6\" name=\"wpforms[fields][91][]\" value=\"International performance\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_6\">International performance<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_9\" name=\"wpforms[fields][91][]\" value=\"Telemedicine service\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_9\">Telemedicine service<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_8\" name=\"wpforms[fields][91][]\" value=\"Telecare service\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_8\">Telecare service<\/label><\/li><\/ul><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_94-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"94\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_94\">Amount of interventions required<\/label><input type=\"text\" id=\"wpforms-58-field_94\" class=\"wpforms-field-large\" name=\"wpforms[fields][94]\" placeholder=\"Specific quantity of interventions\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_92-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"92\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_92\">Request for initiation of intake <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_92\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"0\" data-input=\"true\" name=\"wpforms[fields][92][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_74-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"74\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tDegree of priority\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_75-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"75\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\">Multiple choice <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_75\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_75_1\" name=\"wpforms[fields][75]\" value=\"Low\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_75_1\">Low<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_75_2\" name=\"wpforms[fields][75]\" value=\"Medium\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_75_2\">Medium<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_75_3\" name=\"wpforms[fields][75]\" value=\"High\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_75_3\">High<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_75_4\" name=\"wpforms[fields][75]\" value=\"Request for in-depth information about the service\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_75_4\">Request for in-depth information about the service<\/label><\/li><\/ul><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_76-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"76\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_76\">Additional text<\/label><textarea id=\"wpforms-58-field_76\" class=\"wpforms-field-medium\" name=\"wpforms[fields][76]\" placeholder=\"Additional text\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_73-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"73\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tRequesting Attending Physician\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_66-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"66\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_66\">Requesting Attending Physician <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_66\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][66]\" placeholder=\"Specify name of requesting Attending Physician\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_57-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"57\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tPatient data\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_58-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"58\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_58\">first name last name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_58\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][58]\" placeholder=\"First and Last Name\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_59-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"59\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_59\">Date of birth <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_59\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][59][date]\" placeholder=\"Date of birth\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_109-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"109\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_109\">Country Patient<\/label><select id=\"wpforms-58-field_109\" class=\"wpforms-field-large\" name=\"wpforms[fields][109]\"><option value=\"\" class=\"placeholder\" disabled >Nation<\/option><option value=\"Afghanistan\"  class=\"choice-4 depth-1\"  >Afghanistan<\/option><option value=\"Albania\"  class=\"choice-5 depth-1\"  >Albania<\/option><option value=\"Algeria\"  class=\"choice-6 depth-1\"  >Algeria<\/option><option value=\"Andorra\"  class=\"choice-7 depth-1\"  >Andorra<\/option><option value=\"Angola\"  class=\"choice-8 depth-1\"  >Angola<\/option><option value=\"Eel\"  class=\"choice-9 depth-1\"  >Eel<\/option><option value=\"Antarctica\"  class=\"choice-10 depth-1\"  >Antarctica<\/option><option value=\"Antigua and Barbuda\"  class=\"choice-11 depth-1\"  >Antigua and Barbuda<\/option><option value=\"Saudi Arabia\"  class=\"choice-12 depth-1\"  >Saudi Arabia<\/option><option value=\"Argentina\"  class=\"choice-13 depth-1\"  >Argentina<\/option><option value=\"Armenia\"  class=\"choice-14 depth-1\"  >Armenia<\/option><option value=\"Aruba\"  class=\"choice-15 depth-1\"  >Aruba<\/option><option value=\"Australia\"  class=\"choice-16 depth-1\"  >Australia<\/option><option value=\"Austria\"  class=\"choice-17 depth-1\"  >Austria<\/option><option value=\"Azerbaijan\"  class=\"choice-18 depth-1\"  >Azerbaijan<\/option><option value=\"Bahamas\"  class=\"choice-19 depth-1\"  >Bahamas<\/option><option value=\"Bahrain\"  class=\"choice-20 depth-1\"  >Bahrain<\/option><option value=\"Bangladesh\"  class=\"choice-21 depth-1\"  >Bangladesh<\/option><option value=\"Barbados\"  class=\"choice-22 depth-1\"  >Barbados<\/option><option value=\"Belgium\"  class=\"choice-23 depth-1\"  >Belgium<\/option><option value=\"Belize\"  class=\"choice-24 depth-1\"  >Belize<\/option><option value=\"Benin\"  class=\"choice-25 depth-1\"  >Benin<\/option><option value=\"Bermuda\"  class=\"choice-26 depth-1\"  >Bermuda<\/option><option value=\"Bhutan\"  class=\"choice-27 depth-1\"  >Bhutan<\/option><option value=\"Belarus\"  class=\"choice-28 depth-1\"  >Belarus<\/option><option value=\"Burma\"  class=\"choice-29 depth-1\"  >Burma<\/option><option value=\"Bolivia (plurinational state of)\"  class=\"choice-30 depth-1\"  >Bolivia (plurinational state of)<\/option><option value=\"Bonaire, Saint Eustatius and Saba\"  class=\"choice-31 depth-1\"  >Bonaire, Saint Eustatius and Saba<\/option><option value=\"Bosnia-Herzegovina\"  class=\"choice-32 depth-1\"  >Bosnia-Herzegovina<\/option><option value=\"Botswana\"  class=\"choice-33 depth-1\"  >Botswana<\/option><option value=\"Brazil\"  class=\"choice-34 depth-1\"  >Brazil<\/option><option value=\"Brunei Darrussalam\"  class=\"choice-35 depth-1\"  >Brunei Darrussalam<\/option><option value=\"Bulgaria\"  class=\"choice-36 depth-1\"  >Bulgaria<\/option><option value=\"Burkina Faso\"  class=\"choice-37 depth-1\"  >Burkina Faso<\/option><option value=\"Burundi\"  class=\"choice-38 depth-1\"  >Burundi<\/option><option value=\"Cambodia\"  class=\"choice-39 depth-1\"  >Cambodia<\/option><option value=\"Cameroon\"  class=\"choice-40 depth-1\"  >Cameroon<\/option><option value=\"Canada\"  class=\"choice-41 depth-1\"  >Canada<\/option><option value=\"Cape Verde\"  class=\"choice-42 depth-1\"  >Cape Verde<\/option><option value=\"Chad\"  class=\"choice-43 depth-1\"  >Chad<\/option><option value=\"Chile\"  class=\"choice-44 depth-1\"  >Chile<\/option><option value=\"China\"  class=\"choice-45 depth-1\"  >China<\/option><option value=\"Cyprus\"  class=\"choice-46 depth-1\"  >Cyprus<\/option><option value=\"Colombia\"  class=\"choice-47 depth-1\"  >Colombia<\/option><option value=\"Comoros\"  class=\"choice-48 depth-1\"  >Comoros<\/option><option value=\"Congo\"  class=\"choice-49 depth-1\"  >Congo<\/option><option value=\"Congo (Democratic Republic of the)\"  class=\"choice-50 depth-1\"  >Congo (Democratic Republic of the)<\/option><option value=\"Costa Rica\"  class=\"choice-51 depth-1\"  >Costa Rica<\/option><option value=\"Ivory Coast\"  class=\"choice-52 depth-1\"  >Ivory Coast<\/option><option value=\"Croatia\"  class=\"choice-53 depth-1\"  >Croatia<\/option><option value=\"Cuba\"  class=\"choice-54 depth-1\"  >Cuba<\/option><option value=\"Cura\u00e7ao\"  class=\"choice-55 depth-1\"  >Cura\u00e7ao<\/option><option value=\"Denmark\"  class=\"choice-56 depth-1\"  >Denmark<\/option><option value=\"Dominica\"  class=\"choice-57 depth-1\"  >Dominica<\/option><option value=\"Ecuador\"  class=\"choice-58 depth-1\"  >Ecuador<\/option><option value=\"Egypt\"  class=\"choice-59 depth-1\"  >Egypt<\/option><option value=\"El Salvador\"  class=\"choice-60 depth-1\"  >El Salvador<\/option><option value=\"United Arab Emirates\"  class=\"choice-61 depth-1\"  >United Arab Emirates<\/option><option value=\"Eritrea\"  class=\"choice-62 depth-1\"  >Eritrea<\/option><option value=\"Estonia\"  class=\"choice-63 depth-1\"  >Estonia<\/option><option value=\"Ethiopia\"  class=\"choice-64 depth-1\"  >Ethiopia<\/option><option value=\"Russian Federation\"  class=\"choice-65 depth-1\"  >Russian Federation<\/option><option value=\"Fiji\"  class=\"choice-66 depth-1\"  >Fiji<\/option><option value=\"Philippines\"  class=\"choice-67 depth-1\"  >Philippines<\/option><option value=\"Finland\"  class=\"choice-68 depth-1\"  >Finland<\/option><option value=\"France\"  class=\"choice-69 depth-1\"  >France<\/option><option value=\"Gabon\"  class=\"choice-70 depth-1\"  >Gabon<\/option><option value=\"Gambia\"  class=\"choice-71 depth-1\"  >Gambia<\/option><option value=\"Georgia\"  class=\"choice-72 depth-1\"  >Georgia<\/option><option value=\"South Georgia and the South Sandwich Islands\"  class=\"choice-73 depth-1\"  >South Georgia and the South Sandwich Islands<\/option><option value=\"Germany\"  class=\"choice-74 depth-1\"  >Germany<\/option><option value=\"Ghana\"  class=\"choice-75 depth-1\"  >Ghana<\/option><option value=\"Jamaica\"  class=\"choice-76 depth-1\"  >Jamaica<\/option><option value=\"Japan\"  class=\"choice-77 depth-1\"  >Japan<\/option><option value=\"Gibraltar\"  class=\"choice-78 depth-1\"  >Gibraltar<\/option><option value=\"Djibouti\"  class=\"choice-79 depth-1\"  >Djibouti<\/option><option value=\"Jordan\"  class=\"choice-80 depth-1\"  >Jordan<\/option><option value=\"Greece\"  class=\"choice-81 depth-1\"  >Greece<\/option><option value=\"Grenada\"  class=\"choice-82 depth-1\"  >Grenada<\/option><option value=\"Greenland\"  class=\"choice-83 depth-1\"  >Greenland<\/option><option value=\"Guadeloupe\"  class=\"choice-84 depth-1\"  >Guadeloupe<\/option><option value=\"Guam\"  class=\"choice-85 depth-1\"  >Guam<\/option><option value=\"Guatemala\"  class=\"choice-86 depth-1\"  >Guatemala<\/option><option value=\"Guernsey\"  class=\"choice-87 depth-1\"  >Guernsey<\/option><option value=\"French Guiana\"  class=\"choice-88 depth-1\"  >French Guiana<\/option><option value=\"Guinea\"  class=\"choice-89 depth-1\"  >Guinea<\/option><option value=\"Equatorial Guinea\"  class=\"choice-90 depth-1\"  >Equatorial Guinea<\/option><option value=\"Guinea-Bissau\"  class=\"choice-91 depth-1\"  >Guinea-Bissau<\/option><option value=\"Guyana\"  class=\"choice-92 depth-1\"  >Guyana<\/option><option value=\"Haiti\"  class=\"choice-93 depth-1\"  >Haiti<\/option><option value=\"Honduras\"  class=\"choice-94 depth-1\"  >Honduras<\/option><option value=\"Hong Kong\"  class=\"choice-95 depth-1\"  >Hong Kong<\/option><option value=\"India\"  class=\"choice-96 depth-1\"  >India<\/option><option value=\"Indonesia\"  class=\"choice-97 depth-1\"  >Indonesia<\/option><option value=\"Iran (Islamic Republic of)\"  class=\"choice-98 depth-1\"  >Iran (Islamic Republic of)<\/option><option value=\"Iraq\"  class=\"choice-99 depth-1\"  >Iraq<\/option><option value=\"Ireland (Republic of)\"  class=\"choice-100 depth-1\"  >Ireland (Republic of)<\/option><option value=\"Iceland\"  class=\"choice-101 depth-1\"  >Iceland<\/option><option value=\"Bouvet Island\"  class=\"choice-102 depth-1\"  >Bouvet Island<\/option><option value=\"Isle of Man\"  class=\"choice-103 depth-1\"  >Isle of Man<\/option><option value=\"Christmas Island\"  class=\"choice-104 depth-1\"  >Christmas Island<\/option><option value=\"Island of Saint Barth\u00e9lemy\"  class=\"choice-105 depth-1\"  >Island of Saint Barth\u00e9lemy<\/option><option value=\"Aland Islands\"  class=\"choice-106 depth-1\"  >Aland Islands<\/option><option value=\"Cayman Islands\"  class=\"choice-107 depth-1\"  >Cayman Islands<\/option><option value=\"Cocos Islands (Keeling)\"  class=\"choice-108 depth-1\"  >Cocos Islands (Keeling)<\/option><option value=\"Cook Islands\"  class=\"choice-109 depth-1\"  >Cook Islands<\/option><option value=\"Falkland Islands (Malvinas)\"  class=\"choice-110 depth-1\"  >Falkland Islands (Malvinas)<\/option><option value=\"Faroe Islands\"  class=\"choice-111 depth-1\"  >Faroe Islands<\/option><option value=\"Heard and McDonald Islands\"  class=\"choice-112 depth-1\"  >Heard and McDonald Islands<\/option><option value=\"Northern Mariana Islands\"  class=\"choice-113 depth-1\"  >Northern Mariana Islands<\/option><option value=\"Marshall Islands\"  class=\"choice-114 depth-1\"  >Marshall Islands<\/option><option value=\"Norfolk Islands\"  class=\"choice-115 depth-1\"  >Norfolk Islands<\/option><option value=\"Saint Pierre and Miquelon Islands\"  class=\"choice-116 depth-1\"  >Saint Pierre and Miquelon Islands<\/option><option value=\"Solomon Islands\"  class=\"choice-117 depth-1\"  >Solomon Islands<\/option><option value=\"Svalbard and Jan Mayen Islands\"  class=\"choice-118 depth-1\"  >Svalbard and Jan Mayen Islands<\/option><option value=\"Turks and Caicos Islands\"  class=\"choice-119 depth-1\"  >Turks and Caicos Islands<\/option><option value=\"Virgin Islands (U.S.)\"  class=\"choice-120 depth-1\"  >Virgin Islands (U.S.)<\/option><option value=\"Virgin Islands (British)\"  class=\"choice-121 depth-1\"  >Virgin Islands (British)<\/option><option value=\"Minor outer islands of the United States of America\"  class=\"choice-122 depth-1\"  >Minor outer islands of the United States of America<\/option><option value=\"Israel\"  class=\"choice-123 depth-1\"  >Israel<\/option><option value=\"Italy\"  class=\"choice-124 depth-1\"  >Italy<\/option><option value=\"Kazakhstan\"  class=\"choice-125 depth-1\"  >Kazakhstan<\/option><option value=\"Kenya\"  class=\"choice-126 depth-1\"  >Kenya<\/option><option value=\"Kyrgyzstan\"  class=\"choice-127 depth-1\"  >Kyrgyzstan<\/option><option value=\"Kiribati\"  class=\"choice-128 depth-1\"  >Kiribati<\/option><option value=\"Korea (People&#039;s Democratic Republic of)\"  class=\"choice-129 depth-1\"  >Korea (People's Democratic Republic of)<\/option><option value=\"Korea (Republic of)\"  class=\"choice-130 depth-1\"  >Korea (Republic of)<\/option><option value=\"Kosovo\"  class=\"choice-131 depth-1\"  >Kosovo<\/option><option value=\"Kuwait\"  class=\"choice-132 depth-1\"  >Kuwait<\/option><option value=\"Lesotho\"  class=\"choice-133 depth-1\"  >Lesotho<\/option><option value=\"Latvia\"  class=\"choice-134 depth-1\"  >Latvia<\/option><option value=\"Lebanon\"  class=\"choice-135 depth-1\"  >Lebanon<\/option><option value=\"Liberia\"  class=\"choice-136 depth-1\"  >Liberia<\/option><option value=\"Libya\"  class=\"choice-137 depth-1\"  >Libya<\/option><option value=\"Liechtenstein\"  class=\"choice-138 depth-1\"  >Liechtenstein<\/option><option value=\"Lithuania\"  class=\"choice-139 depth-1\"  >Lithuania<\/option><option value=\"Luxembourg\"  class=\"choice-140 depth-1\"  >Luxembourg<\/option><option value=\"Macau\"  class=\"choice-141 depth-1\"  >Macau<\/option><option value=\"North Macedonia (Republic of)\"  class=\"choice-142 depth-1\"  >North Macedonia (Republic of)<\/option><option value=\"Madagascar\"  class=\"choice-143 depth-1\"  >Madagascar<\/option><option value=\"Jersey\"  class=\"choice-144 depth-1\"  >Jersey<\/option><option value=\"Malawi\"  class=\"choice-145 depth-1\"  >Malawi<\/option><option value=\"Maldives\"  class=\"choice-146 depth-1\"  >Maldives<\/option><option value=\"Malaysia\"  class=\"choice-147 depth-1\"  >Malaysia<\/option><option value=\"Mali\"  class=\"choice-148 depth-1\"  >Mali<\/option><option value=\"Malta\"  class=\"choice-149 depth-1\"  >Malta<\/option><option value=\"Morocco\"  class=\"choice-150 depth-1\"  >Morocco<\/option><option value=\"Martinique\"  class=\"choice-151 depth-1\"  >Martinique<\/option><option value=\"Mauritania\"  class=\"choice-152 depth-1\"  >Mauritania<\/option><option value=\"Mauritius\"  class=\"choice-153 depth-1\"  >Mauritius<\/option><option value=\"Mayotte\"  class=\"choice-154 depth-1\"  >Mayotte<\/option><option value=\"Mexico\"  class=\"choice-155 depth-1\"  >Mexico<\/option><option value=\"Micronesia (Confederation of States of)\"  class=\"choice-156 depth-1\"  >Micronesia (Confederation of States of)<\/option><option value=\"Moldova (Republic of)\"  class=\"choice-157 depth-1\"  >Moldova (Republic of)<\/option><option value=\"Monaco\"  class=\"choice-158 depth-1\"  >Monaco<\/option><option value=\"Mongolia\"  class=\"choice-159 depth-1\"  >Mongolia<\/option><option value=\"Montenegro\"  class=\"choice-160 depth-1\"  >Montenegro<\/option><option value=\"Montserrat\"  class=\"choice-161 depth-1\"  >Montserrat<\/option><option value=\"Mozambique\"  class=\"choice-162 depth-1\"  >Mozambique<\/option><option value=\"Namibia\"  class=\"choice-163 depth-1\"  >Namibia<\/option><option value=\"Nauru\"  class=\"choice-164 depth-1\"  >Nauru<\/option><option value=\"Nepal\"  class=\"choice-165 depth-1\"  >Nepal<\/option><option value=\"Nicaragua\"  class=\"choice-166 depth-1\"  >Nicaragua<\/option><option value=\"Niger\"  class=\"choice-167 depth-1\"  >Niger<\/option><option value=\"Nigeria\"  class=\"choice-168 depth-1\"  >Nigeria<\/option><option value=\"Niue\"  class=\"choice-169 depth-1\"  >Niue<\/option><option value=\"Norway\"  class=\"choice-170 depth-1\"  >Norway<\/option><option value=\"New Caledonia\"  class=\"choice-171 depth-1\"  >New Caledonia<\/option><option value=\"New Zealand\"  class=\"choice-172 depth-1\"  >New Zealand<\/option><option value=\"Oman\"  class=\"choice-173 depth-1\"  >Oman<\/option><option value=\"Netherlands\"  class=\"choice-174 depth-1\"  >Netherlands<\/option><option value=\"Pakistan\"  class=\"choice-175 depth-1\"  >Pakistan<\/option><option value=\"Palau\"  class=\"choice-176 depth-1\"  >Palau<\/option><option value=\"Palestine (State of)\"  class=\"choice-177 depth-1\"  >Palestine (State of)<\/option><option value=\"Panama\"  class=\"choice-178 depth-1\"  >Panama<\/option><option value=\"Papua New Guinea\"  class=\"choice-179 depth-1\"  >Papua New Guinea<\/option><option value=\"Paraguay\"  class=\"choice-180 depth-1\"  >Paraguay<\/option><option value=\"Peru\"  class=\"choice-181 depth-1\"  >Peru<\/option><option value=\"Pitcairn\"  class=\"choice-182 depth-1\"  >Pitcairn<\/option><option value=\"Poland\"  class=\"choice-183 depth-1\"  >Poland<\/option><option value=\"French Polynesia\"  class=\"choice-184 depth-1\"  >French Polynesia<\/option><option value=\"Puerto Rico\"  class=\"choice-185 depth-1\"  >Puerto Rico<\/option><option value=\"Portugal\"  class=\"choice-186 depth-1\"  >Portugal<\/option><option value=\"Qatar\"  class=\"choice-187 depth-1\"  >Qatar<\/option><option value=\"United Kingdom of Great Britain and Northern Ireland\"  class=\"choice-188 depth-1\"  >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"Arab Republic of Syria\"  class=\"choice-189 depth-1\"  >Arab Republic of Syria<\/option><option value=\"Czech Republic\"  class=\"choice-190 depth-1\"  >Czech Republic<\/option><option value=\"Central African Republic\"  class=\"choice-191 depth-1\"  >Central African Republic<\/option><option value=\"Lao People&#039;s Democratic Republic\"  class=\"choice-192 depth-1\"  >Lao People's Democratic Republic<\/option><option value=\"Dominican Republic\"  class=\"choice-193 depth-1\"  >Dominican Republic<\/option><option value=\"Reunion (Island of)\"  class=\"choice-194 depth-1\"  >Reunion (Island of)<\/option><option value=\"Romania\"  class=\"choice-195 depth-1\"  >Romania<\/option><option value=\"Rwanda\"  class=\"choice-196 depth-1\"  >Rwanda<\/option><option value=\"Western Sahara\"  class=\"choice-197 depth-1\"  >Western Sahara<\/option><option value=\"Saint Kitts and Nevis\"  class=\"choice-198 depth-1\"  >Saint Kitts and Nevis<\/option><option value=\"Saint Vincent and the Grenadines\"  class=\"choice-199 depth-1\"  >Saint Vincent and the Grenadines<\/option><option value=\"Saint-Martin (French Part)\"  class=\"choice-200 depth-1\"  >Saint-Martin (French Part)<\/option><option value=\"Samoa\"  class=\"choice-201 depth-1\"  >Samoa<\/option><option value=\"American Samoa\"  class=\"choice-202 depth-1\"  >American Samoa<\/option><option value=\"San Marino\"  class=\"choice-203 depth-1\"  >San Marino<\/option><option value=\"St. Helena, Ascension and Tristan da Cunha\"  class=\"choice-204 depth-1\"  >St. Helena, Ascension and Tristan da Cunha<\/option><option value=\"Saint Lucia\"  class=\"choice-205 depth-1\"  >Saint Lucia<\/option><option value=\"Sao Tome and Principe\"  class=\"choice-206 depth-1\"  >Sao Tome and Principe<\/option><option value=\"Senegal\"  class=\"choice-207 depth-1\"  >Senegal<\/option><option value=\"Serbia\"  class=\"choice-208 depth-1\"  >Serbia<\/option><option value=\"Seychelles\"  class=\"choice-209 depth-1\"  >Seychelles<\/option><option value=\"Sierra Leone\"  class=\"choice-210 depth-1\"  >Sierra Leone<\/option><option value=\"Singapore\"  class=\"choice-211 depth-1\"  >Singapore<\/option><option value=\"Sint Maarten (part of the Netherlands)\"  class=\"choice-212 depth-1\"  >Sint Maarten (part of the Netherlands)<\/option><option value=\"Slovakia\"  class=\"choice-213 depth-1\"  >Slovakia<\/option><option value=\"Slovenia\"  class=\"choice-214 depth-1\"  >Slovenia<\/option><option value=\"Somalia\"  class=\"choice-215 depth-1\"  >Somalia<\/option><option value=\"Spain\"  class=\"choice-216 depth-1\"  >Spain<\/option><option value=\"Sri Lanka\"  class=\"choice-217 depth-1\"  >Sri Lanka<\/option><option value=\"United States of America\"  class=\"choice-218 depth-1\"  >United States of America<\/option><option value=\"Vatican City State\"  class=\"choice-219 depth-1\"  >Vatican City State<\/option><option value=\"South Africa\"  class=\"choice-220 depth-1\"  >South Africa<\/option><option value=\"Sudan\"  class=\"choice-221 depth-1\"  >Sudan<\/option><option value=\"South Sudan\"  class=\"choice-222 depth-1\"  >South Sudan<\/option><option value=\"Suriname\"  class=\"choice-223 depth-1\"  >Suriname<\/option><option value=\"Sweden\"  class=\"choice-224 depth-1\"  >Sweden<\/option><option value=\"Switzerland\"  selected='selected' class=\"choice-225 depth-1\"  >Switzerland<\/option><option value=\"Tajikistan\"  class=\"choice-226 depth-1\"  >Tajikistan<\/option><option value=\"Taiwan, Republic of China\"  class=\"choice-227 depth-1\"  >Taiwan, Republic of China<\/option><option value=\"Tanzania (United Republic of)\"  class=\"choice-228 depth-1\"  >Tanzania (United Republic of)<\/option><option value=\"French Southern Territories\"  class=\"choice-229 depth-1\"  >French Southern Territories<\/option><option value=\"British territory in the Indian Ocean\"  class=\"choice-230 depth-1\"  >British territory in the Indian Ocean<\/option><option value=\"Thailand\"  class=\"choice-231 depth-1\"  >Thailand<\/option><option value=\"East Timor\"  class=\"choice-232 depth-1\"  >East Timor<\/option><option value=\"Togo\"  class=\"choice-233 depth-1\"  >Togo<\/option><option value=\"Tokelau\"  class=\"choice-234 depth-1\"  >Tokelau<\/option><option value=\"Tonga\"  class=\"choice-235 depth-1\"  >Tonga<\/option><option value=\"Trinidad and Tobago\"  class=\"choice-236 depth-1\"  >Trinidad and Tobago<\/option><option value=\"Tunisia\"  class=\"choice-237 depth-1\"  >Tunisia<\/option><option value=\"Turkey\"  class=\"choice-238 depth-1\"  >Turkey<\/option><option value=\"Turkmenistan\"  class=\"choice-239 depth-1\"  >Turkmenistan<\/option><option value=\"Tuvalu\"  class=\"choice-240 depth-1\"  >Tuvalu<\/option><option value=\"Ukraine\"  class=\"choice-241 depth-1\"  >Ukraine<\/option><option value=\"Uganda\"  class=\"choice-242 depth-1\"  >Uganda<\/option><option value=\"Hungary\"  class=\"choice-243 depth-1\"  >Hungary<\/option><option value=\"Uruguay\"  class=\"choice-244 depth-1\"  >Uruguay<\/option><option value=\"Uzbekistan\"  class=\"choice-245 depth-1\"  >Uzbekistan<\/option><option value=\"Vanuatu\"  class=\"choice-246 depth-1\"  >Vanuatu<\/option><option value=\"Venezuela (Bollivian Republic of)\"  class=\"choice-247 depth-1\"  >Venezuela (Bollivian Republic of)<\/option><option value=\"Vietnam\"  class=\"choice-248 depth-1\"  >Vietnam<\/option><option value=\"Wallis and Futuna\"  class=\"choice-249 depth-1\"  >Wallis and Futuna<\/option><option value=\"Yemen\"  class=\"choice-250 depth-1\"  >Yemen<\/option><option value=\"Zambia\"  class=\"choice-251 depth-1\"  >Zambia<\/option><option value=\"Zimbabwe\"  class=\"choice-252 depth-1\"  >Zimbabwe<\/option><option value=\"eSwatini (Kingdom of)\"  class=\"choice-253 depth-1\"  >eSwatini (Kingdom of)<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_60-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"60\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_60\">Address <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-58-field_60\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][60][address1]\" placeholder=\"Address\" required><label for=\"wpforms-58-field_60\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-58-field_60-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][60][city]\" placeholder=\"City\" required><label for=\"wpforms-58-field_60-city\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-58-field_60-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][60][state]\" placeholder=\"Canton\" required><label for=\"wpforms-58-field_60-state\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">State \/ Province \/ Region<\/label><\/div><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_61-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"61\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_61\">Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-58-field_61\" class=\"wpforms-field-large wpforms-field-required\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][61]\" placeholder=\"Phone\" aria-label=\"Phone\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_62-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"62\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_62\">Email<\/label><input type=\"email\" id=\"wpforms-58-field_62\" class=\"wpforms-field-large\" name=\"wpforms[fields][62]\" placeholder=\"Email\" spellcheck=\"false\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_63-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"63\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_63\">Contact person and respective function <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-58-field_63\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][63]\" placeholder=\"Contact person and respective function (Insert: first and last name, relationship to patient)\" required><\/textarea><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_100-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"100\" style=\"display:none;\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-58-field_101-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"101\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_101\">Insurance company<\/label><input type=\"text\" id=\"wpforms-58-field_101\" class=\"wpforms-field-large\" name=\"wpforms[fields][101]\" placeholder=\"Insurance company\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-58-field_102-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"102\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_102\">AVS<\/label><input type=\"text\" id=\"wpforms-58-field_102\" class=\"wpforms-field-large\" name=\"wpforms[fields][102]\" placeholder=\"AVS\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-58-field_103-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"103\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_103\">Insured Number<\/label><input type=\"text\" id=\"wpforms-58-field_103\" class=\"wpforms-field-large\" name=\"wpforms[fields][103]\" placeholder=\"Insured Number\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_67-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"67\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tReason for contact\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_68-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"68\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_68\">Main diagnosis <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_68\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][68]\" placeholder=\"Specific principal diagnosis\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_71-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"71\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_71\">Specific secondary diagnoses   <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_71\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][71]\" placeholder=\"Secondary diagnoses critical to intake\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_82-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"82\" style=\"display:none;\"><label class=\"wpforms-field-label\">Benefits required <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_82\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_1\" name=\"wpforms[fields][82][]\" value=\"Welfare benefits basic care\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_1\">Welfare benefits basic care<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_2\" name=\"wpforms[fields][82][]\" value=\"Nursing services\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_2\">Nursing services<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_4\" name=\"wpforms[fields][82][]\" value=\"Specialized nursing services\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_4\">Specialized nursing services<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_7\" name=\"wpforms[fields][82][]\" value=\"Private benefits\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_7\">Private benefits<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_6\" name=\"wpforms[fields][82][]\" value=\"International performance\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_6\">International performance<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_9\" name=\"wpforms[fields][82][]\" value=\"Telemedicine service\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_9\">Telemedicine service<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_8\" name=\"wpforms[fields][82][]\" value=\"Telecare service\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_8\">Telecare service<\/label><\/li><\/ul><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_72-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"72\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_72\">Amount of interventions required <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_72\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][72]\" placeholder=\"Specific quantity of interventions\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_70-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"70\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_70\">Request for initiation of intake <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_70\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"0\" data-input=\"true\" name=\"wpforms[fields][70][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_77-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"77\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tDegree of priority\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_78-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"78\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\">Multiple choice <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_78\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_78_1\" name=\"wpforms[fields][78]\" value=\"Low\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_78_1\">Low<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_78_2\" name=\"wpforms[fields][78]\" value=\"Medium\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_78_2\">Medium<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_78_3\" name=\"wpforms[fields][78]\" value=\"High\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_78_3\">High<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_78_4\" name=\"wpforms[fields][78]\" value=\"Request for in-depth information about the service\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_78_4\">Request for in-depth information about the service<\/label><\/li><\/ul><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_79-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"79\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_79\">Additional text<\/label><textarea id=\"wpforms-58-field_79\" class=\"wpforms-field-medium\" name=\"wpforms[fields][79]\" placeholder=\"Additional text\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_8-container\" class=\"wpforms-field wpforms-field-gdpr-checkbox flagPrivacy wpforms-conditional-field wpforms-conditional-hide\" data-field-id=\"8\"><label class=\"wpforms-field-label wpforms-label-hide\">Consent Privacy Policy <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_8\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"checkbox\" id=\"wpforms-58-field_8_1\" name=\"wpforms[fields][8][]\" value=\"Consent to processing of personal data: I declare that I have read the privacy policy and consent to the processing of my personal data for the purpose of providing the requested service.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_8_1\">Consent to processing of personal data: I declare that I have read the privacy policy and consent to the processing of my personal data for the purpose of providing the requested service. <span class=\"wpforms-required-label\">*<\/span><\/label><\/li><\/ul><div class=\"wpforms-field-description\">View <a href=\"https:\/\/cad.healthcare\/en\/privacy-policy\/\" target=\"_blank\">privacy policy<\/a><\/div><\/div><div id=\"wpforms-58-field_6-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-id=\"6\"><input type=\"hidden\" id=\"wpforms-58-field_6\" name=\"wpforms[fields][6]\"><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-58-field-hp\" class=\"wpforms-field-label\">Website<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-58-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"58\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/cad.healthcare\/en\/wp-json\/wp\/v2\/pages\/1821\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-58\" class=\"wpforms-submit\" data-alt-text=\"SENDING IN PROGRESS...\" data-submit-text=\"SEND\" aria-live=\"assertive\" value=\"wpforms-submit\">SEND<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\n\t\t\t\t<\/div>\n\t\t\t<\/div><\/p>\n","protected":false},"author":6,"featured_media":0,"parent":0,"menu_order":70,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","inline_featured_image":false,"footnotes":""},"class_list":["post-1821","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Contacts | CAD, 24-hour Home Care in Ticino<\/title>\n<meta name=\"description\" content=\"Do you need fast, personalized home care? 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