{"id":6,"date":"2024-02-04T12:42:46","date_gmt":"2024-02-04T12:42:46","guid":{"rendered":"http:\/\/form.healwise.net\/?page_id=6"},"modified":"2024-11-14T11:32:07","modified_gmt":"2024-11-14T10:32:07","slug":"6-2","status":"publish","type":"page","link":"https:\/\/form.healwise.net\/","title":{"rendered":"Healwise Consultation Form"},"content":{"rendered":"\n<div class=\"wp-block-group alignfull has-background has-global-padding is-layout-constrained wp-container-core-group-is-layout-1 wp-block-group-is-layout-constrained\" style=\"background-color:#3b9095;min-height:100vh;margin-top:0;margin-bottom:0;padding-top:var(--wp--preset--spacing--60);padding-right:var(--wp--preset--spacing--50);padding-bottom:var(--wp--preset--spacing--60);padding-left:var(--wp--preset--spacing--50)\">\n<div style=\"height:0.8rem\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n<style id=\"wpforms-css-vars-root\">\n\t\t\t\t:root {\n\t\t\t\t\t--wpforms-field-border-radius: 3px;\n--wpforms-field-background-color: #ffffff;\n--wpforms-field-border-color: rgba( 0, 0, 0, 0.25 );\n--wpforms-field-text-color: rgba( 0, 0, 0, 0.7 );\n--wpforms-label-color: rgba( 0, 0, 0, 0.85 );\n--wpforms-label-sublabel-color: rgba( 0, 0, 0, 0.55 );\n--wpforms-label-error-color: #d63637;\n--wpforms-button-border-radius: 3px;\n--wpforms-button-background-color: #066aab;\n--wpforms-button-text-color: #ffffff;\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n\n\t\t\t\t}\n\t\t\t<\/style><style id=\"wpforms-css-vars-15-block-3535adcf-4077-418c-ab36-bba2a050d39c\">\n\t\t\t\t#wpforms-15.wpforms-block-3535adcf-4077-418c-ab36-bba2a050d39c {\n\t\t\t\t\t--wpforms-field-text-color: #111111;\n--wpforms-label-color: #ffffff;\n--wpforms-label-error-color: #ff0000;\n--wpforms-button-background-color: #f08046;\n--wpforms-field-size-input-height: 50px;\n--wpforms-field-size-input-spacing: 20px;\n--wpforms-field-size-font-size: 18px;\n--wpforms-field-size-line-height: 21px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 18px;\n--wpforms-field-size-sublabel-spacing: 10px;\n--wpforms-field-size-icon-size: 1.25;\n--wpforms-button-size-font-size: 20px;\n--wpforms-button-size-height: 48px;\n--wpforms-button-size-padding-h: 20px;\n--wpforms-button-size-margin-top: 15px;\n\n\t\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-form-abandonment wpforms-container-save-resume wpforms-block wpforms-block-3535adcf-4077-418c-ab36-bba2a050d39c wpforms-render-modern\" id=\"wpforms-15\"><form id=\"wpforms-form-15\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"15\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F6&#038;wpforms_form_id=15\" data-token=\"2a64113b9c55c29ee0a4d588100abb3f\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-page-indicator progress\" data-indicator=\"progress\" data-indicator-color=\"#f08046\" data-scroll=\"1\" role=\"progressbar\" aria-valuenow=\"1\" aria-valuemin=\"1\" aria-valuemax=\"7\" tabindex=\"-1\"><span class=\"wpforms-page-indicator-page-title\" ><\/span><span class=\"wpforms-page-indicator-page-title-sep\" style=\"display:none;\"> &#8211; <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 7<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:14.285714285714%;background-color:#f08046\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-15-field_17-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"17\"><\/div><div id=\"wpforms-15-field_21-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"21\"><h3 id=\"wpforms-15-field_21\" name=\"wpforms[fields][21]\" aria-errormessage=\"wpforms-15-field_21-error\">Personal Information<\/h3><\/div><div id=\"wpforms-15-field_1-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-15-field_1\">Full Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-15-field_1\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][1]\" aria-errormessage=\"wpforms-15-field_1-error\" required><\/div><div id=\"wpforms-15-field_2-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-15-field_2\">Date of Birth <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-15-field_2\" 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][2][date]\" aria-errormessage=\"wpforms-15-field_2-error\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-15-field_3-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"3\"><fieldset><legend class=\"wpforms-field-label\">Gender <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-15-field_3\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-15-field_3_1\" name=\"wpforms[fields][3]\" value=\"Male\" aria-errormessage=\"wpforms-15-field_3_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15-field_3_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-15-field_3_2\" name=\"wpforms[fields][3]\" value=\"Female\" aria-errormessage=\"wpforms-15-field_3_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15-field_3_2\">Female<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-15-field_4-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-15-field_4\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-15-field_4\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][4]\" spellcheck=\"false\" aria-errormessage=\"wpforms-15-field_4-error\" required><\/div><div id=\"wpforms-15-field_5-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-15-field_5\">Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-15-field_5\" class=\"wpforms-field-large wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][5]\" aria-errormessage=\"wpforms-15-field_5-error\" required><\/div><div id=\"wpforms-15-field_6-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"6\"><fieldset><legend class=\"wpforms-field-label\">Preferred Language for Communication <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-15-field_6\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-15-field_6_1\" name=\"wpforms[fields][6]\" value=\"English\" aria-errormessage=\"wpforms-15-field_6_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15-field_6_1\">English<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-15-field_6_4\" name=\"wpforms[fields][6]\" value=\"Other\" aria-errormessage=\"wpforms-15-field_6_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15-field_6_4\">Other<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-15-field_9-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"9\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-15-field_9\">Please Specify your Preferred Language <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-15-field_9\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-15-field_9-error\" required><\/div><div id=\"wpforms-15-field_14-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-15-field_14\">Country of Residence <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-15-field_14\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][14]\" required=\"required\"><option value=\"Afghanistan\" >Afghanistan<\/option><option value=\"Albania\" >Albania<\/option><option value=\"Algeria\" >Algeria<\/option><option value=\"American Samoa\" >American Samoa<\/option><option value=\"Andorra\" >Andorra<\/option><option value=\"Angola\" >Angola<\/option><option value=\"Anguilla\" >Anguilla<\/option><option value=\"Antarctica\" >Antarctica<\/option><option value=\"Antigua and Barbuda\" >Antigua and Barbuda<\/option><option value=\"Argentina\" >Argentina<\/option><option value=\"Armenia\" >Armenia<\/option><option value=\"Aruba\" >Aruba<\/option><option value=\"Australia\" >Australia<\/option><option value=\"Austria\" >Austria<\/option><option value=\"Azerbaijan\" >Azerbaijan<\/option><option value=\"Bahamas\" >Bahamas<\/option><option value=\"Bahrain\" >Bahrain<\/option><option value=\"Bangladesh\" >Bangladesh<\/option><option value=\"Barbados\" >Barbados<\/option><option value=\"Belarus\" >Belarus<\/option><option value=\"Belgium\" >Belgium<\/option><option value=\"Belize\" >Belize<\/option><option value=\"Benin\" >Benin<\/option><option value=\"Bermuda\" >Bermuda<\/option><option value=\"Bhutan\" >Bhutan<\/option><option value=\"Bolivia (Plurinational State of)\" >Bolivia (Plurinational State of)<\/option><option value=\"Bonaire, Saint Eustatius and Saba\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"Bosnia and Herzegovina\" >Bosnia and Herzegovina<\/option><option value=\"Botswana\" >Botswana<\/option><option value=\"Bouvet Island\" >Bouvet Island<\/option><option value=\"Brazil\" >Brazil<\/option><option value=\"British Indian Ocean Territory\" >British Indian Ocean Territory<\/option><option value=\"Brunei Darussalam\" >Brunei Darussalam<\/option><option value=\"Bulgaria\" >Bulgaria<\/option><option value=\"Burkina Faso\" >Burkina Faso<\/option><option value=\"Burundi\" >Burundi<\/option><option value=\"Cabo Verde\" >Cabo Verde<\/option><option value=\"Cambodia\" >Cambodia<\/option><option value=\"Cameroon\" >Cameroon<\/option><option value=\"Canada\" >Canada<\/option><option value=\"Cayman Islands\" >Cayman Islands<\/option><option value=\"Central African Republic\" >Central African Republic<\/option><option value=\"Chad\" >Chad<\/option><option value=\"Chile\" >Chile<\/option><option value=\"China\" >China<\/option><option value=\"Christmas Island\" >Christmas Island<\/option><option value=\"Cocos (Keeling) Islands\" >Cocos (Keeling) Islands<\/option><option value=\"Colombia\" >Colombia<\/option><option value=\"Comoros\" >Comoros<\/option><option value=\"Congo\" >Congo<\/option><option value=\"Congo (Democratic Republic of the)\" >Congo (Democratic Republic of the)<\/option><option value=\"Cook Islands\" >Cook Islands<\/option><option value=\"Costa Rica\" >Costa Rica<\/option><option value=\"Croatia\" >Croatia<\/option><option value=\"Cuba\" >Cuba<\/option><option value=\"Cura\u00e7ao\" >Cura\u00e7ao<\/option><option value=\"Cyprus\" >Cyprus<\/option><option value=\"Czech Republic\" >Czech Republic<\/option><option value=\"C\u00f4te d&#039;Ivoire\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"Denmark\" >Denmark<\/option><option value=\"Djibouti\" >Djibouti<\/option><option value=\"Dominica\" >Dominica<\/option><option value=\"Dominican Republic\" >Dominican Republic<\/option><option value=\"Ecuador\" >Ecuador<\/option><option value=\"Egypt\" >Egypt<\/option><option value=\"El Salvador\" >El Salvador<\/option><option value=\"Equatorial Guinea\" >Equatorial Guinea<\/option><option value=\"Eritrea\" >Eritrea<\/option><option value=\"Estonia\" >Estonia<\/option><option value=\"Eswatini (Kingdom of)\" >Eswatini (Kingdom of)<\/option><option value=\"Ethiopia\" >Ethiopia<\/option><option value=\"Falkland Islands (Malvinas)\" >Falkland Islands (Malvinas)<\/option><option value=\"Faroe Islands\" >Faroe Islands<\/option><option value=\"Fiji\" >Fiji<\/option><option value=\"Finland\" >Finland<\/option><option value=\"France\" >France<\/option><option value=\"French Guiana\" >French Guiana<\/option><option value=\"French Polynesia\" >French Polynesia<\/option><option value=\"French Southern Territories\" >French Southern Territories<\/option><option value=\"Gabon\" >Gabon<\/option><option value=\"Gambia\" >Gambia<\/option><option value=\"Georgia\" >Georgia<\/option><option value=\"Germany\" >Germany<\/option><option value=\"Ghana\" >Ghana<\/option><option value=\"Gibraltar\" >Gibraltar<\/option><option value=\"Greece\" >Greece<\/option><option value=\"Greenland\" >Greenland<\/option><option value=\"Grenada\" >Grenada<\/option><option value=\"Guadeloupe\" >Guadeloupe<\/option><option value=\"Guam\" >Guam<\/option><option value=\"Guatemala\" >Guatemala<\/option><option value=\"Guernsey\" >Guernsey<\/option><option value=\"Guinea\" >Guinea<\/option><option value=\"Guinea-Bissau\" >Guinea-Bissau<\/option><option value=\"Guyana\" >Guyana<\/option><option value=\"Haiti\" >Haiti<\/option><option value=\"Heard Island and McDonald Islands\" >Heard Island and McDonald Islands<\/option><option value=\"Honduras\" >Honduras<\/option><option value=\"Hong Kong\" >Hong Kong<\/option><option value=\"Hungary\" >Hungary<\/option><option value=\"Iceland\" >Iceland<\/option><option value=\"India\" >India<\/option><option value=\"Indonesia\" >Indonesia<\/option><option value=\"Iran (Islamic Republic of)\" >Iran (Islamic Republic of)<\/option><option value=\"Iraq\" >Iraq<\/option><option value=\"Ireland (Republic of)\" >Ireland (Republic of)<\/option><option value=\"Isle of Man\" >Isle of Man<\/option><option value=\"Israel\" >Israel<\/option><option value=\"Italy\" >Italy<\/option><option value=\"Jamaica\" >Jamaica<\/option><option value=\"Japan\" >Japan<\/option><option value=\"Jersey\" >Jersey<\/option><option value=\"Jordan\" >Jordan<\/option><option value=\"Kazakhstan\" >Kazakhstan<\/option><option value=\"Kenya\" >Kenya<\/option><option value=\"Kiribati\" >Kiribati<\/option><option value=\"Korea (Democratic People&#039;s Republic of)\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"Korea (Republic of)\" >Korea (Republic of)<\/option><option value=\"Kosovo\" >Kosovo<\/option><option value=\"Kuwait\" >Kuwait<\/option><option value=\"Kyrgyzstan\" >Kyrgyzstan<\/option><option value=\"Lao People&#039;s Democratic Republic\" >Lao People&#039;s Democratic Republic<\/option><option value=\"Latvia\" >Latvia<\/option><option value=\"Lebanon\" >Lebanon<\/option><option value=\"Lesotho\" >Lesotho<\/option><option value=\"Liberia\" >Liberia<\/option><option value=\"Libya\" >Libya<\/option><option value=\"Liechtenstein\" >Liechtenstein<\/option><option value=\"Lithuania\" >Lithuania<\/option><option value=\"Luxembourg\" >Luxembourg<\/option><option value=\"Macao\" >Macao<\/option><option value=\"Madagascar\" >Madagascar<\/option><option value=\"Malawi\" >Malawi<\/option><option value=\"Malaysia\" >Malaysia<\/option><option value=\"Maldives\" >Maldives<\/option><option value=\"Mali\" >Mali<\/option><option value=\"Malta\" >Malta<\/option><option value=\"Marshall Islands\" >Marshall Islands<\/option><option value=\"Martinique\" >Martinique<\/option><option value=\"Mauritania\" >Mauritania<\/option><option value=\"Mauritius\" >Mauritius<\/option><option value=\"Mayotte\" >Mayotte<\/option><option value=\"Mexico\" >Mexico<\/option><option value=\"Micronesia (Federated States of)\" >Micronesia (Federated States of)<\/option><option value=\"Moldova (Republic of)\" >Moldova (Republic of)<\/option><option value=\"Monaco\" >Monaco<\/option><option value=\"Mongolia\" >Mongolia<\/option><option value=\"Montenegro\" >Montenegro<\/option><option value=\"Montserrat\" >Montserrat<\/option><option value=\"Morocco\" >Morocco<\/option><option value=\"Mozambique\" >Mozambique<\/option><option value=\"Myanmar\" >Myanmar<\/option><option value=\"Namibia\" >Namibia<\/option><option value=\"Nauru\" >Nauru<\/option><option value=\"Nepal\" >Nepal<\/option><option value=\"Netherlands\" >Netherlands<\/option><option value=\"New Caledonia\" >New Caledonia<\/option><option value=\"New Zealand\" >New Zealand<\/option><option value=\"Nicaragua\" >Nicaragua<\/option><option value=\"Niger\" >Niger<\/option><option value=\"Nigeria\" >Nigeria<\/option><option value=\"Niue\" >Niue<\/option><option value=\"Norfolk Island\" >Norfolk Island<\/option><option value=\"North Macedonia (Republic of)\" >North Macedonia (Republic of)<\/option><option value=\"Northern Mariana Islands\" >Northern Mariana Islands<\/option><option value=\"Norway\" >Norway<\/option><option value=\"Oman\" >Oman<\/option><option value=\"Pakistan\" >Pakistan<\/option><option value=\"Palau\" >Palau<\/option><option value=\"Palestine (State of)\" >Palestine (State of)<\/option><option value=\"Panama\" >Panama<\/option><option value=\"Papua New Guinea\" >Papua New Guinea<\/option><option value=\"Paraguay\" >Paraguay<\/option><option value=\"Peru\" >Peru<\/option><option value=\"Philippines\" >Philippines<\/option><option value=\"Pitcairn\" >Pitcairn<\/option><option value=\"Poland\" >Poland<\/option><option value=\"Portugal\" >Portugal<\/option><option value=\"Puerto Rico\" >Puerto Rico<\/option><option value=\"Qatar\" >Qatar<\/option><option value=\"Romania\" >Romania<\/option><option value=\"Russian Federation\" >Russian Federation<\/option><option value=\"Rwanda\" >Rwanda<\/option><option value=\"R\u00e9union\" >R\u00e9union<\/option><option value=\"Saint Barth\u00e9lemy\" >Saint Barth\u00e9lemy<\/option><option value=\"Saint Helena, Ascension and Tristan da Cunha\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"Saint Kitts and Nevis\" >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\" >Saint Lucia<\/option><option value=\"Saint Martin (French part)\" >Saint Martin (French part)<\/option><option value=\"Saint Pierre and Miquelon\" >Saint Pierre and Miquelon<\/option><option value=\"Saint Vincent and the Grenadines\" >Saint Vincent and the Grenadines<\/option><option value=\"Samoa\" >Samoa<\/option><option value=\"San Marino\" >San Marino<\/option><option value=\"Sao Tome and Principe\" >Sao Tome and Principe<\/option><option value=\"Saudi Arabia\" >Saudi Arabia<\/option><option value=\"Senegal\" >Senegal<\/option><option value=\"Serbia\" >Serbia<\/option><option value=\"Seychelles\" >Seychelles<\/option><option value=\"Sierra Leone\" >Sierra Leone<\/option><option value=\"Singapore\" >Singapore<\/option><option value=\"Sint Maarten (Dutch part)\" >Sint Maarten (Dutch part)<\/option><option value=\"Slovakia\" >Slovakia<\/option><option value=\"Slovenia\" >Slovenia<\/option><option value=\"Solomon Islands\" >Solomon Islands<\/option><option value=\"Somalia\" >Somalia<\/option><option value=\"South Africa\" >South Africa<\/option><option value=\"South Georgia and the South Sandwich Islands\" >South Georgia and the South Sandwich Islands<\/option><option value=\"South Sudan\" >South Sudan<\/option><option value=\"Spain\" >Spain<\/option><option value=\"Sri Lanka\" >Sri Lanka<\/option><option value=\"Sudan\" >Sudan<\/option><option value=\"Suriname\" >Suriname<\/option><option value=\"Svalbard and Jan Mayen\" >Svalbard and Jan Mayen<\/option><option value=\"Sweden\" >Sweden<\/option><option value=\"Switzerland\" >Switzerland<\/option><option value=\"Syrian Arab Republic\" >Syrian Arab Republic<\/option><option value=\"Taiwan, Republic of China\" >Taiwan, Republic of China<\/option><option value=\"Tajikistan\" >Tajikistan<\/option><option value=\"Tanzania (United Republic of)\" >Tanzania (United Republic of)<\/option><option value=\"Thailand\" >Thailand<\/option><option value=\"Timor-Leste\" >Timor-Leste<\/option><option value=\"Togo\" >Togo<\/option><option value=\"Tokelau\" >Tokelau<\/option><option value=\"Tonga\" >Tonga<\/option><option value=\"Trinidad and Tobago\" >Trinidad and Tobago<\/option><option value=\"Tunisia\" >Tunisia<\/option><option value=\"Turkmenistan\" >Turkmenistan<\/option><option value=\"Turks and Caicos Islands\" >Turks and Caicos Islands<\/option><option value=\"Tuvalu\" >Tuvalu<\/option><option value=\"T\u00fcrkiye\" >T\u00fcrkiye<\/option><option value=\"Uganda\" >Uganda<\/option><option value=\"Ukraine\" >Ukraine<\/option><option value=\"United Arab Emirates\" >United Arab Emirates<\/option><option value=\"United Kingdom of Great Britain and Northern Ireland\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"United States Minor Outlying Islands\" >United States Minor Outlying Islands<\/option><option value=\"United States of America\" >United States of America<\/option><option value=\"Uruguay\" >Uruguay<\/option><option value=\"Uzbekistan\" >Uzbekistan<\/option><option value=\"Vanuatu\" >Vanuatu<\/option><option value=\"Vatican City State\" >Vatican City State<\/option><option value=\"Venezuela (Bolivarian Republic of)\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"Vietnam\" >Vietnam<\/option><option value=\"Virgin Islands (British)\" >Virgin Islands (British)<\/option><option value=\"Virgin Islands (U.S.)\" >Virgin Islands (U.S.)<\/option><option value=\"Wallis and Futuna\" >Wallis and Futuna<\/option><option value=\"Western Sahara\" >Western Sahara<\/option><option value=\"Yemen\" >Yemen<\/option><option value=\"Zambia\" >Zambia<\/option><option value=\"Zimbabwe\" >Zimbabwe<\/option><option value=\"\u00c5land Islands\" >\u00c5land Islands<\/option><\/select><\/div><div id=\"wpforms-15-field_16-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"16\"><div class=\"wpforms-clear wpforms-pagebreak-center\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"1\" data-formid=\"15\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-15-field_22-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"22\"><h3 id=\"wpforms-15-field_22\" name=\"wpforms[fields][22]\" aria-errormessage=\"wpforms-15-field_22-error\">Medical History and Current Condition<\/h3><\/div><div id=\"wpforms-15-field_23-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"23\"><fieldset><legend class=\"wpforms-field-label\">Do you have a medical diagnosis for your condition?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-15-field_23\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-15-field_23_1\" name=\"wpforms[fields][23]\" value=\"Yes\" aria-errormessage=\"wpforms-15-field_23_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15-field_23_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-15-field_23_2\" name=\"wpforms[fields][23]\" value=\"No\" aria-errormessage=\"wpforms-15-field_23_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15-field_23_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-15-field_24-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"24\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-15-field_24\">Please specify the diagnosis <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-15-field_24\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][24]\" aria-errormessage=\"wpforms-15-field_24-error\" required><\/div><div id=\"wpforms-15-field_25-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-15-field_25\">Please describe your symptoms <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-15-field_25\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][25]\" aria-errormessage=\"wpforms-15-field_25-error\" required><\/textarea><\/div><div id=\"wpforms-15-field_26-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-15-field_26\">How long have you been experiencing these symptoms? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-15-field_26\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][26]\" aria-errormessage=\"wpforms-15-field_26-error\" aria-describedby=\"wpforms-15-field_26-description\" required><div id=\"wpforms-15-field_26-description\" class=\"wpforms-field-description\">E.g., one week, six months, etc.<\/div><\/div><div id=\"wpforms-15-field_27-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-15-field_27\">What is the medical condition that you are seeking help for? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-15-field_27\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][27]\" aria-errormessage=\"wpforms-15-field_27-error\" required><\/div><div id=\"wpforms-15-field_28-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"28\"><fieldset><legend class=\"wpforms-field-label\">Have you undergone any treatments or surgeries for your current condition?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-15-field_28\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-15-field_28_1\" name=\"wpforms[fields][28]\" value=\"Yes\" aria-errormessage=\"wpforms-15-field_28_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15-field_28_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-15-field_28_2\" name=\"wpforms[fields][28]\" value=\"No\" aria-errormessage=\"wpforms-15-field_28_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15-field_28_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-15-field_29-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"29\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-15-field_29\">Please provide details of the treatments or surgeries you have undergone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-15-field_29\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][29]\" aria-errormessage=\"wpforms-15-field_29-error\" required><\/textarea><\/div><div id=\"wpforms-15-field_30-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"30\"><fieldset><legend class=\"wpforms-field-label\">Are you currently taking any medication? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-15-field_30\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-15-field_30_1\" name=\"wpforms[fields][30]\" value=\"Yes\" aria-errormessage=\"wpforms-15-field_30_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15-field_30_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-15-field_30_2\" name=\"wpforms[fields][30]\" value=\"No\" aria-errormessage=\"wpforms-15-field_30_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15-field_30_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-15-field_32-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"32\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-15-field_32\">Please list the medications and dosages <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-15-field_32\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][32]\" aria-errormessage=\"wpforms-15-field_32-error\" required><\/textarea><\/div><div id=\"wpforms-15-field_34-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"34\"><div class=\"wpforms-clear wpforms-pagebreak-center\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"2\" data-formid=\"15\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"2\" data-formid=\"15\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3  \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-15-field_35-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"35\"><h3 id=\"wpforms-15-field_35\" name=\"wpforms[fields][35]\" aria-errormessage=\"wpforms-15-field_35-error\">Medical Documentation<\/h3><\/div><div id=\"wpforms-15-field_8-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-15-field_8\">Please upload any relevant medical documents.<\/label><input type=\"file\" id=\"wpforms-15-field_8\" data-rule-extension=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\" data-rule-maxsize=\"5242880000\" name=\"wpforms_15_8\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.webp,.avif,.ico,.heic,.heif,.heics,.heifs,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.css,.vtt,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.pdf,.class,.tar,.zip,.gz,.gzip,.rar,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages\" aria-errormessage=\"wpforms-15-field_8-error\" aria-describedby=\"wpforms-15-field_8-description\" ><div id=\"wpforms-15-field_8-description\" class=\"wpforms-field-description\">E.g., medical reports, diagnostic test results, referral letters, etc.<\/div><\/div><div id=\"wpforms-15-field_10-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"10\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-15-field_10\" aria-hidden=\"false\">File Upload<\/label><input type=\"file\" id=\"wpforms-15-field_10\" data-rule-extension=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\" data-rule-maxsize=\"5242880000\" name=\"wpforms_15_10\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.webp,.avif,.ico,.heic,.heif,.heics,.heifs,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.css,.vtt,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.pdf,.class,.tar,.zip,.gz,.gzip,.rar,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages\" aria-errormessage=\"wpforms-15-field_10-error\" ><\/div><div id=\"wpforms-15-field_11-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"11\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-15-field_11\" aria-hidden=\"false\">File Upload<\/label><input type=\"file\" id=\"wpforms-15-field_11\" data-rule-extension=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\" data-rule-maxsize=\"5242880000\" name=\"wpforms_15_11\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.webp,.avif,.ico,.heic,.heif,.heics,.heifs,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.css,.vtt,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.pdf,.class,.tar,.zip,.gz,.gzip,.rar,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages\" aria-errormessage=\"wpforms-15-field_11-error\" ><\/div><div id=\"wpforms-15-field_12-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"12\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-15-field_12\" aria-hidden=\"false\">File Upload<\/label><input type=\"file\" id=\"wpforms-15-field_12\" data-rule-extension=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\" data-rule-maxsize=\"5242880000\" name=\"wpforms_15_12\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.webp,.avif,.ico,.heic,.heif,.heics,.heifs,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.css,.vtt,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.pdf,.class,.tar,.zip,.gz,.gzip,.rar,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages\" aria-errormessage=\"wpforms-15-field_12-error\" ><\/div><div id=\"wpforms-15-field_13-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"13\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-15-field_13\" aria-hidden=\"false\">File Upload<\/label><input type=\"file\" id=\"wpforms-15-field_13\" data-rule-extension=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\" data-rule-maxsize=\"5242880000\" name=\"wpforms_15_13\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.webp,.avif,.ico,.heic,.heif,.heics,.heifs,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.css,.vtt,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.pdf,.class,.tar,.zip,.gz,.gzip,.rar,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages\" aria-errormessage=\"wpforms-15-field_13-error\" ><\/div><div id=\"wpforms-15-field_36-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"36\"><div class=\"wpforms-clear wpforms-pagebreak-center\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"3\" data-formid=\"15\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"3\" data-formid=\"15\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4  \" data-page=\"4\" style=\"display:none;\"><div id=\"wpforms-15-field_37-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"37\"><h3 id=\"wpforms-15-field_37\" name=\"wpforms[fields][37]\" aria-errormessage=\"wpforms-15-field_37-error\">Health Insurance and Financial Information<\/h3><\/div><div id=\"wpforms-15-field_38-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"38\"><fieldset><legend class=\"wpforms-field-label\">Do you have health insurance that covers international medical treatment? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-15-field_38\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-15-field_38_1\" name=\"wpforms[fields][38]\" value=\"Yes\" aria-errormessage=\"wpforms-15-field_38_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15-field_38_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-15-field_38_2\" name=\"wpforms[fields][38]\" value=\"No\" aria-errormessage=\"wpforms-15-field_38_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15-field_38_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-15-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-15-field_39\">Please provide the name of the insurance company and your policy number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-15-field_39\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][39]\" aria-errormessage=\"wpforms-15-field_39-error\" required><\/div><div id=\"wpforms-15-field_40-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"40\"><div class=\"wpforms-clear wpforms-pagebreak-center\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"4\" data-formid=\"15\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"4\" data-formid=\"15\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-5  \" data-page=\"5\" style=\"display:none;\"><div id=\"wpforms-15-field_41-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"41\"><h3 id=\"wpforms-15-field_41\" name=\"wpforms[fields][41]\" aria-errormessage=\"wpforms-15-field_41-error\">Treatment Preferences and Travel Details<\/h3><\/div><div id=\"wpforms-15-field_42-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-15-field_42\">Do you have any specific preferences or requirements for your treatment? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-15-field_42\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][42]\" aria-errormessage=\"wpforms-15-field_42-error\" aria-describedby=\"wpforms-15-field_42-description\" required><\/textarea><div id=\"wpforms-15-field_42-description\" class=\"wpforms-field-description\">E.g., language, gender of the doctor, religious considerations, etc.<\/div><\/div><div id=\"wpforms-15-field_43-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-15-field_43\">What is your intended timeframe for treatment?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-15-field_43\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][43]\" aria-errormessage=\"wpforms-15-field_43-error\" aria-describedby=\"wpforms-15-field_43-description\" required><div id=\"wpforms-15-field_43-description\" class=\"wpforms-field-description\">E.g., as soon as possible, within the next 3 months, etc.<\/div><\/div><div id=\"wpforms-15-field_44-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"44\"><fieldset><legend class=\"wpforms-field-label\">Will you be traveling alone or with companions?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-15-field_44\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-15-field_44_1\" name=\"wpforms[fields][44]\" value=\"Alone\" aria-errormessage=\"wpforms-15-field_44_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15-field_44_1\">Alone<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-15-field_44_2\" name=\"wpforms[fields][44]\" value=\"With companions\" aria-errormessage=\"wpforms-15-field_44_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15-field_44_2\">With companions<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-15-field_45-container\" class=\"wpforms-field wpforms-field-number-slider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"45\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-15-field_45\">Please specify the number of companions<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-15-field_45\" class=\"wpforms-field-large\" name=\"wpforms[fields][45]\" value=\"1\" aria-errormessage=\"wpforms-15-field_45-error\"\t\tvalue=\"1\"\n\tmin=\"1\"\n\tmax=\"12\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>1<\/b><\/div>\n<\/div><div id=\"wpforms-15-field_47-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"47\"><div class=\"wpforms-clear wpforms-pagebreak-center\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"5\" data-formid=\"15\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"5\" data-formid=\"15\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-6  \" data-page=\"6\" style=\"display:none;\"><div id=\"wpforms-15-field_48-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"48\"><h3 id=\"wpforms-15-field_48\" name=\"wpforms[fields][48]\" aria-errormessage=\"wpforms-15-field_48-error\">Additional Information<\/h3><\/div><div id=\"wpforms-15-field_49-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-15-field_49\">Is there any other information you think is important for us to know about your medical condition or travel preferences? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-15-field_49\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][49]\" aria-errormessage=\"wpforms-15-field_49-error\" required><\/textarea><\/div><div id=\"wpforms-15-field_50-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"50\"><div class=\"wpforms-clear wpforms-pagebreak-center\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"6\" data-formid=\"15\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"6\" data-formid=\"15\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-7 last \" data-page=\"7\" style=\"display:none;\"><div id=\"wpforms-15-field_51-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"51\"><h3 id=\"wpforms-15-field_51\" name=\"wpforms[fields][51]\" aria-errormessage=\"wpforms-15-field_51-error\">Consent and Privacy<\/h3><\/div><div id=\"wpforms-15-field_52-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"52\"><fieldset><legend class=\"wpforms-field-label\">Do you consent to our privacy policy and the use of your data to assess your medical treatment options? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-15-field_52\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-15-field_52_1\" name=\"wpforms[fields][52]\" value=\"Yes\" aria-errormessage=\"wpforms-15-field_52_1-error\" aria-describedby=\"wpforms-15-field_52-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15-field_52_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-15-field_52_2\" name=\"wpforms[fields][52]\" value=\"No\" aria-errormessage=\"wpforms-15-field_52_2-error\" aria-describedby=\"wpforms-15-field_52-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15-field_52_2\">No<\/label><\/li><\/ul><div id=\"wpforms-15-field_52-description\" class=\"wpforms-field-description\">This consent is required for us to be able to proceed with your consultation.<\/div><\/fieldset><\/div><div id=\"wpforms-15-field_54-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"54\"><fieldset><legend class=\"wpforms-field-label\">Do you consent to be contacted by our partner clinics and hospitals for further evaluation? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-15-field_54\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-15-field_54_1\" name=\"wpforms[fields][54]\" value=\"Yes\" aria-errormessage=\"wpforms-15-field_54_1-error\" aria-describedby=\"wpforms-15-field_54-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15-field_54_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-15-field_54_2\" name=\"wpforms[fields][54]\" value=\"No\" aria-errormessage=\"wpforms-15-field_54_2-error\" aria-describedby=\"wpforms-15-field_54-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15-field_54_2\">No<\/label><\/li><\/ul><div id=\"wpforms-15-field_54-description\" class=\"wpforms-field-description\">This consent is required for us to be able to proceed with your consultation.<\/div><\/fieldset><\/div><div id=\"wpforms-15-field_18-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"18\"><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha wpforms-is-recaptcha-type-v2\" style=\"display:none;\"><div class=\"g-recaptcha\" data-sitekey=\"6LeEcmYpAAAAAOjE-eq2Tt300m9Je7Vwt4wno2av\"><\/div><input type=\"text\" name=\"g-recaptcha-hidden\" class=\"wpforms-recaptcha-hidden\" style=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\" data-rule-recaptcha=\"1\"><\/div><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"15\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-15\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/form.healwise.net\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/form><\/div>  <!-- .wpforms-container -->\n<div class=\"wpforms-save-resume-confirmation\" id=\"wpforms-save-resume-confirmation-15\" style=\"display: none\">\n\n\t\n\t<div class=\"message\">\n\t\t<p>Your form entry has been saved and a unique link has been created which you can access to continue filling out this form.<\/p>\n<p>Enter your email address to receive the link via email. 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