{"id":41241,"date":"2025-09-29T12:42:16","date_gmt":"2025-09-29T10:42:16","guid":{"rendered":"https:\/\/www.medelit.com\/dott\/jet-popup\/gf15-rich-disp-popup\/"},"modified":"2025-10-01T13:43:44","modified_gmt":"2025-10-01T11:43:44","slug":"gf15-rich-disp-popup","status":"publish","type":"jet-popup","link":"https:\/\/www.medelit.com\/dott\/jet-popup\/gf15-rich-disp-popup\/","title":{"rendered":"GF15 Rich Disp Popup"},"content":{"rendered":"\t\t<div data-elementor-type=\"jet-popup\" data-elementor-id=\"41241\" class=\"elementor elementor-41241\" data-elementor-post-type=\"jet-popup\">\n\t\t\t\t<div class=\"elementor-element elementor-element-c63e04a e-flex e-con-boxed e-con e-parent\" data-id=\"c63e04a\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-21a5499 elementor-widget elementor-widget-shortcode\" data-id=\"21a5499\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_14' style='display:none'><style>#gform_wrapper_14[data-form-index=\"0\"].gform-theme{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 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#204ce5;--gf-color-in-ctrl-primary-rgb: 32, 76, 229;--gf-color-in-ctrl-primary-contrast: #fff;--gf-color-in-ctrl-primary-contrast-rgb: 255, 255, 255;--gf-color-in-ctrl-primary-darker: #001AB3;--gf-color-in-ctrl-primary-lighter: #527EFF;--gf-color-in-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-in-ctrl-light-rgb: 17, 35, 55;--gf-color-in-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-in-ctrl-light-lighter: #F5F5F5;--gf-color-in-ctrl-dark: #585e6a;--gf-color-in-ctrl-dark-rgb: 88, 94, 106;--gf-color-in-ctrl-dark-darker: #112337;--gf-color-in-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-radius: 3px;--gf-font-size-secondary: 14px;--gf-font-size-tertiary: 13px;--gf-icon-ctrl-number: url(\"data:image\/svg+xml,%3Csvg width='8' height='14' viewBox='0 0 8 14' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 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#112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-btn-bg-color-hover-tertiary: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_14' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indica i campi obbligatori<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_14' id='gform_14'  action='\/dott\/wp-json\/wp\/v2\/jet-popup\/41241#gf_14' data-formid='14' novalidate><input type=\"hidden\" name=\"gpuid_existing_value_90\" id=\"gpuid_existing_value_90\" value=\"7e3e2dc7086e13f14d146a36118ef35a\" \/><input type=\"hidden\" value=\"0\" name=\"gpps_page_progression_14\" \/>\n        <div id='gf_progressbar_wrapper_14' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Passo <span class='gf_step_current_page'>1<\/span> di <span class='gf_step_page_count'>10<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_10' style='width:10%;'><span>10%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_14_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_14' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><div id=\"field_14_182\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"><label id='gfield_label_14_182' class='gfield_label gform-field-label' for='input_14_182'><span class='gform-field-label__text'>X\/Twitter<\/span><\/label><div class='ginput_container'><input name='input_182' id='input_14_182' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_14_182'>Questo campo serve per la convalida e dovrebbe essere lasciato inalterato.<\/div><\/div><div id=\"field_14_124\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"c63f11d5\" data-field-span=\"6\"><label id='gfield_label_14_124' class='gfield_label gform-field-label' for='input_14_124'><span class='gform-field-label__text'>CN<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_14_124' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_153\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"c63f11d5\" data-field-span=\"6\"><label id='gfield_label_14_153' class='gfield_label gform-field-label' for='input_14_153'><span class='gform-field-label__text'>feecode<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_153' id='input_14_153' type='text' value='XXX6' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"588861d5\" data-field-span=\"12\"><legend id='gfield_label_14_72' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Che preferenze ha per il suo Appuntamento?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_72'>\n\t\t\t<div class='gchoice gchoice_14_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='PRIMA POSSIBILE'  id='choice_14_72_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_14_72_0 gfield_label_14_72\"   \/>\n\t\t\t\t\t<label for='choice_14_72_0' id='label_14_72_0' class='gform-field-label gform-field-label--type-inline'>PRIMA POSSIBILE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Prima Possibile TRANNE Questa Data e Orario'  id='choice_14_72_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_72_1' id='label_14_72_1' class='gform-field-label gform-field-label--type-inline'>Prima Possibile TRANNE Questa Data e Orario<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_72_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='In Una SPECIFICA Data'  id='choice_14_72_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_72_2' id='label_14_72_2' class='gform-field-label gform-field-label--type-inline'>In Una SPECIFICA Data<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_72_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='In Una Specifica FASCIA ORARIA'  id='choice_14_72_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_72_3' id='label_14_72_3' class='gform-field-label gform-field-label--type-inline'>In Una Specifica FASCIA ORARIA<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_77\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"66557503\" data-field-span=\"12\"><legend id='gfield_label_14_77' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>In Quale Fascia Oraria vorrebbe l&#039;appuntamento?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_77'>\n\t\t\t<div class='gchoice gchoice_14_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='QUALSIASI ORARIO'  id='choice_14_77_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_14_77_0 gfield_label_14_77\"   \/>\n\t\t\t\t\t<label for='choice_14_77_0' id='label_14_77_0' class='gform-field-label gform-field-label--type-inline'>QUALSIASI ORARIO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='MATTINO 08.00-12.00'  id='choice_14_77_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_77_1' id='label_14_77_1' class='gform-field-label gform-field-label--type-inline'>MATTINO 08.00-12.00<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_77_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='POMERIGGIO 12.00-20.00'  id='choice_14_77_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_77_2' id='label_14_77_2' class='gform-field-label gform-field-label--type-inline'>POMERIGGIO 12.00-20.00<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_73\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"055ae460\" data-field-span=\"12\"><label id='gfield_label_14_73' class='gfield_label gform-field-label' for='input_14_73'><span class='gform-field-label__text'>Data di NON Disponibilit\u00e0<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='gg\/mm\/aaaa'\n\t\t\t\t\tid='input_14_73'\n\t\t\t\t\tclass='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_73'\n\t\t\t\t value=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_14_73' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_14_73' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_14_73' aria-label='Data di NON Disponibilit\u00e0: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_14_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"c1d892b8\" data-field-span=\"12\"><legend id='gfield_label_14_74' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Selezioni lo specifico Orario in cui NON \u00e8 Disponibile<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_74'>\n\t\t\t<div class='gchoice gchoice_14_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='NON Disponibile la MATTINA'  id='choice_14_74_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_14_74_0 gfield_label_14_74\"   \/>\n\t\t\t\t\t<label for='choice_14_74_0' id='label_14_74_0' class='gform-field-label gform-field-label--type-inline'>NON Disponibile la MATTINA<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='NON Disponibile il POMERIGGIO'  id='choice_14_74_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_74_1' id='label_14_74_1' class='gform-field-label gform-field-label--type-inline'>NON Disponibile il POMERIGGIO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_74_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='NON Disponibile TUTTO IL GIORNO'  id='choice_14_74_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_74_2' id='label_14_74_2' class='gform-field-label gform-field-label--type-inline'>NON Disponibile TUTTO IL GIORNO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_75\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"b2dc0829\" data-field-span=\"12\"><label id='gfield_label_14_75' class='gfield_label gform-field-label' for='input_14_75'><span class='gform-field-label__text'>Data SPECIFICA richiesta per l&#039;appuntamento<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='gg\/mm\/aaaa'\n\t\t\t\t\tid='input_14_75'\n\t\t\t\t\tclass='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_75'\n\t\t\t\t value='\/\/'\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_14_75' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_14_75' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_14_75' aria-label='Data SPECIFICA richiesta per l'appuntamento: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_14_76\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"8aaac0f6\" data-field-span=\"12\"><legend id='gfield_label_14_76' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Che Preferenza di Orario ha?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_76'>\n\t\t\t<div class='gchoice gchoice_14_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Nessuna VA BENE TUTTO IL GIORNO'  id='choice_14_76_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_14_76_0 gfield_label_14_76\"   \/>\n\t\t\t\t\t<label for='choice_14_76_0' id='label_14_76_0' class='gform-field-label gform-field-label--type-inline'>Nessuna VA BENE TUTTO IL GIORNO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='MATTINA 08.00-12.00'  id='choice_14_76_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_76_1' id='label_14_76_1' class='gform-field-label gform-field-label--type-inline'>MATTINA 08.00-12.00<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_76_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='POMERIGGIO 12.00-20.00'  id='choice_14_76_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_76_2' id='label_14_76_2' class='gform-field-label gform-field-label--type-inline'>POMERIGGIO 12.00-20.00<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_84\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"6e0a76cc\" data-field-span=\"12\"><label id='gfield_label_14_84' class='gfield_label gform-field-label' for='input_14_84'><span class='gform-field-label__text'>Ulteriori note sui Tempi del\/degli Appuntamento\/i<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_14_84' type='text' value='' class='large'  aria-describedby=\"gfield_description_14_84\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_14_84'>\ud83d\udc46\ud83c\udffb Se ha ulteriori specifiche e\/o ha necessit\u00e0 di pi\u00f9 di un appuntamento informi il professionista qui <\/div><\/div><div id=\"field_14_154\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"cc61766c\" data-field-span=\"3\"><label id='gfield_label_14_154' class='gfield_label gform-field-label' for='input_14_154'><span class='gform-field-label__text'>SERV CODE<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_154' id='input_14_154' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_157\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"cc61766c\" data-field-span=\"3\"><label id='gfield_label_14_157' class='gfield_label gform-field-label' for='input_14_157'><span class='gform-field-label__text'>SERV TYPE<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_157' id='input_14_157' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_142\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"cc61766c\" data-field-span=\"3\"><label id='gfield_label_14_142' class='gfield_label gform-field-label' for='input_14_142'><span class='gform-field-label__text'>SERV FIELD<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_142' id='input_14_142' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_144\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"cc61766c\" data-field-span=\"3\"><label id='gfield_label_14_144' class='gfield_label gform-field-label' for='input_14_144'><span class='gform-field-label__text'>SERV SUBFIELD<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_144' id='input_14_144' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <button type='button' id='gform_next_button_14_178' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Successivo<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_14_2' class='gform_page' data-js='page-field-id-178' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_14_2' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><div id=\"field_14_179\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"7c63b124\" data-field-span=\"12\"><p style=\"text-align: justify; font-size: 18px; font-weight: bold; margin: 0;\">\n  Riepilogo Visita\n<\/p>\n<\/div><div id=\"field_14_171\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"52f87ae0\" data-field-span=\"6\"><label id='gfield_label_14_171' class='gfield_label gform-field-label' for='input_14_171'><span class='gform-field-label__text'>-SERVIZIO IN PRENOTAZIONE:<\/span><\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_171' id='input_14_171' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_169\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"52f87ae0\" data-field-span=\"6\"><label id='gfield_label_14_169' class='gfield_label gform-field-label' for='input_14_169'><span class='gform-field-label__text'>DETTAGLI SERVIZIO<\/span><\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_169' id='input_14_169' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_175\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"c581c9b5\" data-field-span=\"4\"><label id='gfield_label_14_175' class='gfield_label gform-field-label' for='input_14_175'><span class='gform-field-label__text'>META 1 FEE CODES<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_175' id='input_14_175' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_174\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"c581c9b5\" data-field-span=\"4\"><label id='gfield_label_14_174' class='gfield_label gform-field-label' for='input_14_174'><span class='gform-field-label__text'>META 2 FEE CODES<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_174' id='input_14_174' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_176\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"c581c9b5\" data-field-span=\"4\"><label id='gfield_label_14_176' class='gfield_label gform-field-label' for='input_14_176'><span class='gform-field-label__text'>META 3 FEE CODES<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_176' id='input_14_176' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_139\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"72eee405\" data-field-span=\"3\"><label id='gfield_label_14_139' class='gfield_label gform-field-label' for='input_14_139'><span class='gform-field-label__text'>REFERRAL REQUIRED<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_14_139' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_138\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"72eee405\" data-field-span=\"3\"><label id='gfield_label_14_138' class='gfield_label gform-field-label' for='input_14_138'><span class='gform-field-label__text'>PRESCRIPTION REQUIRED<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_138' id='input_14_138' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_167\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"72eee405\" data-field-span=\"3\"><label id='gfield_label_14_167' class='gfield_label gform-field-label' for='input_14_167'><span class='gform-field-label__text'>BOOKABLE BY<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_167' id='input_14_167' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_168\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"72eee405\" data-field-span=\"3\"><label id='gfield_label_14_168' class='gfield_label gform-field-label' for='input_14_168'><span class='gform-field-label__text'>RETURNING STOP BOOKING<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_168' id='input_14_168' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_155\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"001d33c7\" data-field-span=\"6\"><label id='gfield_label_14_155' class='gfield_label gform-field-label' for='input_14_155'><span class='gform-field-label__text'>PRO CODE<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_155' id='input_14_155' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_160\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"001d33c7\" data-field-span=\"6\"><label id='gfield_label_14_160' class='gfield_label gform-field-label' for='input_14_160'><span class='gform-field-label__text'>AREA<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_160' id='input_14_160' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_170\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"6db61fb8\" data-field-span=\"12\"><label id='gfield_label_14_170' class='gfield_label gform-field-label' for='input_14_170'><span class='gform-field-label__text'>DETTAGLI PROFESSIONISTA<\/span><\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_170' id='input_14_170' type='text' value='Ti invieremo la migliore proposta in base alle tue esigenze.' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_177\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden gfield--choice-align-vertical\" data-group-id=\"974d7caf\" data-field-span=\"12\"><legend id='gfield_label_14_177' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Medelit Help<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_177'>\n\t\t\t<div class='gchoice gchoice_14_177_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='Si. Dammi altre opzioni in caso di non risposta.'  id='choice_14_177_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_14_177\" aria-labelledby=\"label_14_177_0 gfield_label_14_177\"   \/>\n\t\t\t\t\t<label for='choice_14_177_0' id='label_14_177_0' class='gform-field-label gform-field-label--type-inline'>Si. Dammi altre opzioni in caso di non risposta.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_177_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='No. Preferisco aspettare ma desidero solo il professionista che ho opzionato.'  id='choice_14_177_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_177_1' id='label_14_177_1' class='gform-field-label gform-field-label--type-inline'>No. Preferisco aspettare ma desidero solo il professionista che ho opzionato.<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_14_177'>- Permetti a Medelit di eventualmente contattare altri professionisti in caso quello da te richiesto non dovesse rispondere o dovesse ritardare nella risposta.\n- Sarai libero di scegliere successivamente se accettare o meno.<\/div><\/fieldset><div id=\"field_14_162\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"5bcbc348\" data-field-span=\"6\"><label id='gfield_label_14_162' class='gfield_label gform-field-label' for='input_14_162'><span class='gform-field-label__text'>BOLLO<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_162' id='input_14_162' type='text' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_14_161\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"5bcbc348\" data-field-span=\"6\"><label id='gfield_label_14_161' class='gfield_label gform-field-label' for='input_14_161'><span class='gform-field-label__text'>SUGGESTED FEE<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_161' id='input_14_161' type='text' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_14_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden gfield--choice-align-vertical\" data-group-id=\"eed4d5fb\" data-field-span=\"12\"><legend id='gfield_label_14_5' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Sono un paziente<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_5'>\n\t\t\t<div class='gchoice gchoice_14_5_0'>\n\t\t\t\t\t<input disabled='disabled' class='gfield-choice-input gf-default-disabled' name='input_5' type='radio' value='Nuovo'  id='choice_14_5_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_14_5_0 gfield_label_14_5\"   \/>\n\t\t\t\t\t<label for='choice_14_5_0' id='label_14_5_0' class='gform-field-label gform-field-label--type-inline'>Nuovo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_5_1'>\n\t\t\t\t\t<input disabled='disabled' class='gfield-choice-input gf-default-disabled' name='input_5' type='radio' value='Di Ritorno'  id='choice_14_5_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_5_1' id='label_14_5_1' class='gform-field-label gform-field-label--type-inline'>Di Ritorno<\/label>\n\t\t\t<\/div><\/div><input type=\"hidden\" id=\"gwro_hidden_capture_14_5\" name=\"gwro_hidden_capture_14_5\" value=\"\" class=\"gf-default-disabled\" \/><\/div><\/fieldset><div id=\"field_14_19\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_hidden\" data-group-id=\"7164075e\" data-field-span=\"12\"><label id='gfield_label_14_19' class='gfield_label gform-field-label' for='input_14_19'><span class='gform-field-label__text'>Email<\/span><\/label><div class='gfield_description' id='gfield_description_14_19'>Controlla la casella Inbox della tua email, ti invieremo a breve un'opzione di prenotazione.<\/div><div class='ginput_container ginput_container_email'>\n                            <input readonly='readonly' name='input_19' id='input_14_19' type='email' value='' class='medium'     aria-invalid=\"false\" aria-describedby=\"gfield_description_14_19\" \/>\n                        <\/div><\/div><fieldset id=\"field_14_166\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"a2a0ab4b\" data-field-span=\"12\"><legend id='gfield_label_14_166' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Indirizzo VISITA<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_14_166' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_14_166_1_container' >\n                                        <input readonly='readonly' type='text' name='input_166.1' id='input_14_166_1' value=''    aria-required='false'    aria-labelledby=\"input_14_166_1_label gfield_label_14_166\"\/>\n                                        <label for='input_14_166_1' id='input_14_166_1_label' class='gform-field-label gform-field-label--type-sub '>Via\/Piazza\/Corso e numero civico<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_14_166_3_container' >\n                                    <input readonly='readonly' type='text' name='input_166.3' id='input_14_166_3' value=''    aria-required='false'    \/>\n                                    <label for='input_14_166_3' id='input_14_166_3_label' class='gform-field-label gform-field-label--type-sub '>Localit\u00e0<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_14_166_4_container' >\n                                        <input readonly='readonly' type='text' name='input_166.4' id='input_14_166_4' value=''      aria-required='false'    \/>\n                                        <label for='input_14_166_4' id='input_14_166_4_label' class='gform-field-label gform-field-label--type-sub '>Stato \/ Provincia \/ Regione<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_14_166_5_container' >\n                                    <input readonly='readonly' type='text' name='input_166.5' id='input_14_166_5' value=''    aria-required='false'    \/>\n                                    <label for='input_14_166_5' id='input_14_166_5_label' class='gform-field-label gform-field-label--type-sub '>CAP \/ Codice postale<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_14_166_6_container' >\n                                        <select class='gf-default-disabled' disabled='disabled' name='input_166.6' id='input_14_166_6'   aria-required='false'    ><option value='' ><\/option><option value='AF' >Afghanistan<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antartide<\/option><option value='AG' >Antigua e Barbuda<\/option><option value='SA' >Arabia Saudita<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BE' >Belgio<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BY' >Bielorussia<\/option><option value='MM' >Birmania<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius e Saba<\/option><option value='BA' >Bosnia-Erzegovina<\/option><option value='BW' >Botswana<\/option><option value='BR' >Brasile<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambogia<\/option><option value='CM' >Camerun<\/option><option value='CA' >Canada<\/option><option value='CV' >Capo Verde<\/option><option value='TD' >Chad<\/option><option value='CL' >Cile<\/option><option value='CN' >Cina<\/option><option value='CY' >Cipro<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comore<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Repubblica Democratica del<\/option><option value='KP' >Corea, (Repubblica Democratica Popolare di)<\/option><option value='KR' >Corea, Repubblica di<\/option><option value='CI' >Costa d&#039;Avorio<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croazia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='DK' >Danimarca<\/option><option value='DM' >Dominica<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egitto<\/option><option value='SV' >El Salvador<\/option><option value='AE' >Emirati Arabi Uniti<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >eSwatini<\/option><option value='ET' >Etiopia<\/option><option value='RU' >Federazione Russa<\/option><option value='FJ' >Fiji<\/option><option value='PH' >Filippine<\/option><option value='FI' >Finlandia<\/option><option value='FR' >Francia<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germania<\/option><option value='GH' >Ghana<\/option><option value='JM' >Giamaica<\/option><option value='JP' >Giappone<\/option><option value='GI' >Gibilterra<\/option><option value='DJ' >Gibuti<\/option><option value='JO' >Giordania<\/option><option value='GR' >Grecia<\/option><option value='GD' >Grenada<\/option><option value='GL' >Groenlandia<\/option><option value='GP' >Guadalupa<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GF' >Guiana Francese<\/option><option value='GN' >Guinea<\/option><option value='GQ' >Guinea Equatoriale<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Irlanda<\/option><option value='IS' >Islanda<\/option><option value='BV' >Isola di Bouvet<\/option><option value='IM' >Isola di Man<\/option><option value='CX' >Isola di Natale<\/option><option value='BL' >Isola di Saint Barth\u00e9lemy<\/option><option value='AX' >Isole Aland<\/option><option value='KY' >Isole Cayman<\/option><option value='CC' >Isole Cocos<\/option><option value='CK' >Isole Cook<\/option><option value='FK' >Isole Falkland<\/option><option value='FO' >Isole Faroe<\/option><option value='HM' >Isole Heard e McDonald<\/option><option value='MP' >Isole Marianne Settentrionali<\/option><option value='MH' >Isole Marshall<\/option><option value='UM' >Isole minori esterne degli Stati Uniti d&#039;America<\/option><option value='NF' >Isole Norfolk<\/option><option value='PM' >Isole Saint Pierre e Miquelon<\/option><option value='SB' >Isole Salomone<\/option><option value='SJ' >Isole Svalbard e Jan Mayen<\/option><option value='TC' >Isole Turks e Caicos<\/option><option value='VI' >Isole vergini americane<\/option><option value='VG' >Isole Vergini britanniche<\/option><option value='IL' >Israele<\/option><option value='IT' >Italia<\/option><option value='GS' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='KZ' >Kazakistan<\/option><option value='KE' >Kenya<\/option><option value='KG' >Kirghizistan<\/option><option value='KI' >Kiribati<\/option><option value='KW' >Kuwait<\/option><option value='LA' >Laos<\/option><option value='LS' >Lesotho<\/option><option value='LV' >Lettonia<\/option><option value='LB' >Libano<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libia<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lituania<\/option><option value='LU' >Lussemburgo<\/option><option value='MO' >Macao<\/option><option value='MK' >Macedonia del Nord<\/option><option value='MG' >Madagascar<\/option><option value='JE' >Maglia<\/option><option value='MW' >Malawi<\/option><option value='MV' >Maldive<\/option><option value='MY' >Malesia<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MA' >Marocco<\/option><option value='MQ' >Martinica<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Messico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldavia<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MZ' >Mozambico<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NO' >Norvegia<\/option><option value='NC' >Nuova Caledonia<\/option><option value='NZ' >Nuova Zelanda<\/option><option value='OM' >Oman<\/option><option value='NL' >Paesi Bassi<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua Nuova Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Polonia<\/option><option value='PF' >Polynesia Francese<\/option><option value='PR' >Porto Rico<\/option><option value='PT' >Portogallo<\/option><option value='QA' >Qatar<\/option><option value='GB' >Regno Unito<\/option><option value='SY' >Repubblica Araba di Siria<\/option><option value='CZ' >Repubblica Ceca<\/option><option value='CF' >Repubblica Centrafricana<\/option><option value='DO' >Repubblica Dominicana<\/option><option value='RE' >Riunione (Isola della)<\/option><option value='RO' >Romania<\/option><option value='RW' >Ruanda<\/option><option value='EH' >Sahara Occidentale<\/option><option value='KN' >Saint Kitts e Nevis<\/option><option value='VC' >Saint Vincent e Grenadine<\/option><option value='MF' >Saint-Martin<\/option><option value='WS' >Samoa<\/option><option value='AS' >Samoa americane<\/option><option value='SM' >San Marino<\/option><option value='SH' >Sant&#039;Elena, Ascensione e Tristan da Cunha<\/option><option value='LC' >Santa Lucia<\/option><option value='ST' >Sao Tome e Pr\u00edncipe<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SX' >Sint Maarten<\/option><option value='SK' >Slovacchia<\/option><option value='SI' >Slovenia<\/option><option value='SO' >Somalia<\/option><option value='ES' >Spagna<\/option><option value='LK' >Sri Lanka<\/option><option value='US' >Stati Uniti<\/option><option value='PS' >Stato della Palestina<\/option><option value='ZA' >Sudafrica<\/option><option value='SD' >Sudan<\/option><option value='SS' >Sudan del Sud<\/option><option value='SR' >Suriname<\/option><option value='SE' >Svezia<\/option><option value='CH' >Svizzera<\/option><option value='TJ' >Tagikistan<\/option><option value='TW' >Taiwan<\/option><option value='TZ' >Tanzania (Repubblica Unita della)<\/option><option value='TF' >Territori Meridionali Francesi<\/option><option value='IO' >Territorio Britannico nell&#039;Oceano Indiano<\/option><option value='TH' >Thailandia<\/option><option value='TL' >Timor Est<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad e Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turchia<\/option><option value='TM' >Turkmenistan<\/option><option value='TV' >Tuvalu<\/option><option value='UA' >Ucraina<\/option><option value='UG' >Uganda<\/option><option value='HU' >Ungheria<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vaticano (Santa Sede)<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis e Futuna<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select>\n                                        <label for='input_14_166_6' id='input_14_166_6_label' class='gform-field-label gform-field-label--type-sub '>Nazione<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <input type=\"hidden\" id=\"gwro_hidden_capture_14_166_6\" name=\"gwro_hidden_capture_14_166_6\" value=\"\" class=\"gf-default-disabled\" \/><\/div><\/fieldset><div id=\"field_14_148\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"4908c7ec\" data-field-span=\"12\"><label id='gfield_label_14_148' class='gfield_label gform-field-label' for='input_14_148'><span class='gform-field-label__text'>SAME ADDRESS?<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_148' id='input_14_148' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_14_180' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Precedente<\/button> <button type='button' id='gform_next_button_14_180' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Successivo<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_14_3' class='gform_page' data-js='page-field-id-180' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_14_3' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><div id=\"field_14_128\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"3c59a201\" data-field-span=\"12\"><label id='gfield_label_14_128' class='gfield_label gform-field-label' for='input_14_128'><span class='gform-field-label__text'>FIRST SEARCH Returning PT ID<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_14_128' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_173\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"701d37a5\" data-field-span=\"12\"><label id='gfield_label_14_173' class='gfield_label gform-field-label' for='input_14_173'><span class='gform-field-label__text'>Codice Fiscale Returning PT<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_173' id='input_14_173' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"cf7acc8b\" data-field-span=\"12\"><label id='gfield_label_14_31' class='gfield_label gform-field-label' for='input_14_31'><span class='gform-field-label__text'>Codice Fiscale del PAZIENTE<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_14_31'>Per favore compilare tutti e 16 i caratteri e in STAMPATELLO e inserire unicamente il codice fiscale italiano DELLA PERSONA CHE VERRA' VISITATA. \n<\/div><div class='ginput_container ginput_container_text'><input name='input_31' id='input_14_31' type='text' value='' class='large'  aria-describedby=\"gfield_description_14_31\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_96\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"acd4a245\" data-field-span=\"12\"><label id='gfield_label_14_96' class='gfield_label gform-field-label' for='input_14_96'><span class='gform-field-label__text'>SECONDARY SEARCH Returning PT ID<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_14_96' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_102\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"5048aef7\" data-field-span=\"12\"><label id='gfield_label_14_102' class='gfield_label gform-field-label' for='input_14_102'><span class='gform-field-label__text'>DOB RETURNING PT<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input readonly='readonly'\n\t\t\t\t\tplaceholder='gg\/mm\/aaaa'\n\t\t\t\t\tid='input_14_102'\n\t\t\t\t\tclass='gpro-disabled-datepicker dmy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_102'\n\t\t\t\t value=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_14_102' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_14_102' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_14_102' aria-label='DOB RETURNING PT: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<input type=\"hidden\" id=\"gwro_hidden_capture_14_102\" name=\"gwro_hidden_capture_14_102\" value=\"\" class=\"gf-default-disabled\" \/><\/div><\/div><div id=\"field_14_125\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"552079a3\" data-field-span=\"12\"><label id='gfield_label_14_125' class='gfield_label gform-field-label' for='input_14_125'><span class='gform-field-label__text'>NEW\/RETURNING PT @new_returning<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_14_125' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_9\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"a1b2385f\" data-field-span=\"12\"><label id='gfield_label_14_9' class='gfield_label gform-field-label' for='input_14_9'><span class='gform-field-label__text'>CELLULARE da contattare<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_14_9'>Inserire un CELLULARE<\/div><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_14_9' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_14_9\"   \/><\/div><\/div><div id=\"field_14_30\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"40f51a0e\" data-field-span=\"12\"><label id='gfield_label_14_30' class='gfield_label gform-field-label' for='input_14_30'><span class='gform-field-label__text'>Data di Nascita del PAZIENTE<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='gg\/mm\/aaaa'\n\t\t\t\t\tid='input_14_30'\n\t\t\t\t\tclass='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_30'\n\t\t\t\t value=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_14_30' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_14_30' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_14_30' aria-label='Data di Nascita del PAZIENTE: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_14_111\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"463b4af5\" data-field-span=\"12\"><label id='gfield_label_14_111' class='gfield_label gform-field-label' for='input_14_111'><span class='gform-field-label__text'>L&#039;indirizzo di fatturazione \u00e8 sempre lo stesso dell&#039;ultima volta?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_14_111'>ATTENZIONE! Se l'indirizzo NON \u00e8 lo stesso, rischia di ricevere una fattura errata!<\/div><div class='ginput_container ginput_container_select'><select name='input_111' id='input_14_111' class='large gfield_select'  aria-describedby=\"gfield_description_14_111\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='SI' >SI<\/option><option value='NO \/ NON SONO SICURO\/A' >NO \/ NON SONO SICURO\/A<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_14_109' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Precedente<\/button> <button type='button' id='gform_next_button_14_109' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Successivo<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_14_4' class='gform_page' data-js='page-field-id-109' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_14_4' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><div id=\"field_14_130\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"687eaad6\" data-field-span=\"12\"><p style=\"font-size: 18px; text-align: justify;\">\n  Pu\u00f2 prenotare questo servizio solo chi ha gi\u00e0 svolto una prima visita. Se \u00e8 la sua prima prenotazione, la invitiamo a scegliere il servizio di prima visita.\n<\/p>\n<\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_14_129' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Precedente<\/button> <button type='button' id='gform_next_button_14_129' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Successivo<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_14_5' class='gform_page' data-js='page-field-id-129' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_14_5' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><div id=\"field_14_126\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"36f4d1ce\" data-field-span=\"12\"><label id='gfield_label_14_126' class='gfield_label gform-field-label' for='input_14_126'><span class='gform-field-label__text'>PATIENT ID<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_14_126' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_121\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"3f22796a\" data-field-span=\"12\"><h3 class=\"gsection_title\">INFORMAZIONI PAZIENTE<\/h3><\/div><fieldset id=\"field_14_49\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"73eb916a\" data-field-span=\"12\"><legend id='gfield_label_14_49' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Nome e Cognome del PAZIENTE<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_14_49'>\u261d\ufe0f\nATTENZIONE!  Vanno ESCLUSIVAMENTE inseriti i dati della persona che verr\u00e0 VISITATA in tutti i campi.\n\nSi raccomanda di inserire il SECONDO NOME se presente\/Inserito nel proprio CODICE FISCALE <\/div><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_14_49'>\n                            <span id='input_14_49_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_49.2' id='input_14_49_2'    aria-required='false'   aria-describedby=\"gfield_description_14_49\" aria-labelledby=\"input_14_49_2_label gfield_label_14_49\">\n                          <option value=''><\/option><option value='Dr.' >Dr.<\/option><option value='Prof.' >Prof.<\/option><option value='Rev.' >Rev.<\/option><option value='Sig.' >Sig.<\/option><option value='Sig.ina' >Sig.ina<\/option><option value='Sig.ra' >Sig.ra<\/option><option value='Avv.' >Avv.<\/option>\n                      <\/select>\n                                                    <label for='input_14_49_2' id='input_14_49_2_label' class='gform-field-label gform-field-label--type-sub '>Prefisso<\/label>\n                                                  <\/span>\n                            <span id='input_14_49_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_49.3' id='input_14_49_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_14_49_3' id='input_14_49_3_label' class='gform-field-label gform-field-label--type-sub '>Nome<\/label>\n                                                <\/span>\n                            <span id='input_14_49_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_49.4' id='input_14_49_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_14_49_4' id='input_14_49_4_label' class='gform-field-label gform-field-label--type-sub '>Secondo Nome (se c'e')<\/label>\n                                                <\/span>\n                            <span id='input_14_49_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_49.6' id='input_14_49_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_14_49_6' id='input_14_49_6_label' class='gform-field-label gform-field-label--type-sub '>Cognome<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_14_113\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"d0471c1b\" data-field-span=\"12\"><legend id='gfield_label_14_113' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Nome e Cognome<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_14_113'>\n                            <span id='input_14_113_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select class='gf-default-disabled' disabled='disabled' name='input_113.2' id='input_14_113_2'    aria-required='false'   aria-labelledby=\"input_14_113_2_label gfield_label_14_113\">\n                          <option value=''><\/option><option value='Don' >Don<\/option><option value='Dr.' >Dr.<\/option><option value='Dr.ssa' >Dr.ssa<\/option><option value='Prof.' >Prof.<\/option><option value='Prof.ssa' >Prof.ssa<\/option><option value='Sig.' >Sig.<\/option><option value='Sig.ra' >Sig.ra<\/option>\n                      <\/select>\n                                                    <label for='input_14_113_2' id='input_14_113_2_label' class='gform-field-label gform-field-label--type-sub '>Prefisso<\/label>\n                                                  <\/span>\n                            <span id='input_14_113_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input readonly='readonly' type='text' name='input_113.3' id='input_14_113_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_14_113_3' id='input_14_113_3_label' class='gform-field-label gform-field-label--type-sub '>Nome<\/label>\n                                                <\/span>\n                            <span id='input_14_113_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input readonly='readonly' type='text' name='input_113.4' id='input_14_113_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_14_113_4' id='input_14_113_4_label' class='gform-field-label gform-field-label--type-sub '>Medio<\/label>\n                                                <\/span>\n                            <span id='input_14_113_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input readonly='readonly' type='text' name='input_113.6' id='input_14_113_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_14_113_6' id='input_14_113_6_label' class='gform-field-label gform-field-label--type-sub '>Cognome<\/label>\n                                                <\/span>\n                            \n                        <input type=\"hidden\" id=\"gwro_hidden_capture_14_113_2\" name=\"gwro_hidden_capture_14_113_2\" value=\"\" class=\"gf-default-disabled\" \/><input type=\"hidden\" id=\"gwro_hidden_capture_14_113_3\" name=\"gwro_hidden_capture_14_113_3\" value=\"\" class=\"gf-default-disabled\" \/><input type=\"hidden\" id=\"gwro_hidden_capture_14_113_4\" name=\"gwro_hidden_capture_14_113_4\" value=\"\" class=\"gf-default-disabled\" \/><input type=\"hidden\" id=\"gwro_hidden_capture_14_113_6\" name=\"gwro_hidden_capture_14_113_6\" value=\"\" class=\"gf-default-disabled\" \/><input type=\"hidden\" id=\"gwro_hidden_capture_14_113_8\" name=\"gwro_hidden_capture_14_113_8\" value=\"\" class=\"gf-default-disabled\" \/><\/div><\/fieldset><div id=\"field_14_15\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"f9696fef\" data-field-span=\"12\"><label id='gfield_label_14_15' class='gfield_label gform-field-label' for='input_14_15'><span class='gform-field-label__text'>Cellulare \/ Telefono 2<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_14_15' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_14_15\"   \/><\/div><div class='gfield_description' id='gfield_description_14_15'>Per favore lasciateci un secondo recapito nel caso avessimo problemi a contattare il primo.<\/div><\/div><div id=\"field_14_98\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"8f889cdf\" data-field-span=\"12\"><label id='gfield_label_14_98' class='gfield_label gform-field-label' for='input_14_98'><span class='gform-field-label__text'>TELEFONO PZ<\/span><\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_98' id='input_14_98' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_103\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"2c585f8d\" data-field-span=\"12\"><label id='gfield_label_14_103' class='gfield_label gform-field-label' for='input_14_103'><span class='gform-field-label__text'>Returning Phone 2<\/span><\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_103' id='input_14_103' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_14_10' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Precedente<\/button> <button type='button' id='gform_next_button_14_10' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Successivo<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_14_6' class='gform_page' data-js='page-field-id-10' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_14_6' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><fieldset id=\"field_14_181\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"a21a1ce3\" data-field-span=\"12\"><legend id='gfield_label_14_181' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Numero di Partecipanti al Corso<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_181'>\n\t\t\t<div class='gchoice gchoice_14_181_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_181' type='radio' value='2'  id='choice_14_181_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_14_181_0 gfield_label_14_181\"   \/>\n\t\t\t\t\t<label for='choice_14_181_0' id='label_14_181_0' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_181_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_181' type='radio' value='3'  id='choice_14_181_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_181_1' id='label_14_181_1' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_181_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_181' type='radio' value='4'  id='choice_14_181_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_181_2' id='label_14_181_2' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_181_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_181' type='radio' value='5'  id='choice_14_181_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_181_3' id='label_14_181_3' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_135\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"d27c2013\" data-field-span=\"12\"><label id='gfield_label_14_135' class='gfield_label gform-field-label' for='input_14_135'><span class='gform-field-label__text'>Motivo della Prenotazione e Sintomi\/Disturbi<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea' data-text-counter-max='2000' data-text-counter-template='{current} \/ {max} caratteri'><textarea name='input_135' id='input_14_135' class='textarea large'  aria-describedby=\"gfield_description_14_135\" maxlength='2000'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_14_135'>ATTENZIONE! \nMINIMO 4 PAROLE! \nQuesto campo va compilato con maggiori informazioni possibili. \nSe questo campo non viene compilato con informazioni complete, la vostra prenotazione potr\u00e0 subire dei ritardi in quanto il professionista potrebbe necessitare di pi\u00f9 dettagli per potervi fornire disponibilit\u00e0.<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_14_69' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Precedente<\/button> <button type='button' id='gform_next_button_14_69' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Successivo<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_14_7' class='gform_page' data-js='page-field-id-69' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_14_7' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><div id=\"field_14_146\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"3e36b53b\" data-field-span=\"12\"><label id='gfield_label_14_146' class='gfield_label gform-field-label' for='gform_browse_button_14_146'><span class='gform-field-label__text'>Allega Richiesta dell&#039;Avvocato<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_14_146' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_14_146&quot;,&quot;container&quot;:&quot;gform_multifile_upload_14_146&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_14_146&quot;,&quot;filelist&quot;:&quot;gform_preview_14_146&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.medelit.com\\\/dott\\\/?gf_page=8f90a311dee1416&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.medelit.com\\\/dott\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.medelit.com\\\/dott\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;File consentiti&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;35840000b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:14,&quot;field_id&quot;:146,&quot;_gform_file_upload_nonce_14_146&quot;:&quot;13a3bf27c4&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_14_146&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_14_146' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Trascina i file qui oppure <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_14_146' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_14_146 gfield_description_14_146\"  >Seleziona i file<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_14_146'>Dimensione max del file: 34 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_14_146'><\/ul> <div id='gform_preview_14_146' class='ginput_preview_list'><\/div><\/div><div class='gfield_description' id='gfield_description_14_146'>ATTENZIONE! \nPer poter accedere a questo servizio \u00e8 necessaria una lettera dell\u2019avvocato che assiste il paziente.\nLa lettera deve:\n- essere datata entro gli ultimi 2 mesi,\n- essere redatta su carta intestata e riportare tutti i recapiti dello studio legale,\n- specificare con chiarezza il tipo di perizia medica richiesta (es. valutazione del danno biologico, responsabilit\u00e0 professionale, ecc.), e\n- fornire una breve motivazione della richiesta, indicando il contesto in cui la perizia verr\u00e0 utilizzata (ad esempio, procedimento legale in corso, richiesta risarcitoria, accertamento stragiudiziale, ecc.)<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_14_141' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Precedente<\/button> <button type='button' id='gform_next_button_14_141' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Successivo<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_14_8' class='gform_page' data-js='page-field-id-141' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_14_8' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><div id=\"field_14_23\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"1ffec4cb\" data-field-span=\"12\"><label id='gfield_label_14_23' class='gfield_label gform-field-label' for='gform_browse_button_14_23'><span class='gform-field-label__text'>Ricette per Esami del Sangue\/Analisi<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_14_23' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_14_23&quot;,&quot;container&quot;:&quot;gform_multifile_upload_14_23&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_14_23&quot;,&quot;filelist&quot;:&quot;gform_preview_14_23&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.medelit.com\\\/dott\\\/?gf_page=8f90a311dee1416&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.medelit.com\\\/dott\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.medelit.com\\\/dott\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;File consentiti&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;35840000b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:14,&quot;field_id&quot;:23,&quot;_gform_file_upload_nonce_14_23&quot;:&quot;4cbb90bd09&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;5&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_14_23&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_14_23' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Trascina i file qui oppure <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_14_23' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_14_23 gfield_description_14_23\"  >Seleziona i file<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_14_23'>Dimensione max del file: 34 MB, Numero max di file: 5.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_14_23'><\/ul> <div id='gform_preview_14_23' class='ginput_preview_list'><\/div><\/div><div class='gfield_description' id='gfield_description_14_23'>Per prenotare il servizio di prelievo a domicilio, caricare le ricette qui (massimo 5 richieste). NB Non ci \u00e8 possibile eseguire alcuna prenotazione di prelievo senza aver ricevuto copia delle ricette.<\/div><\/div><div id=\"field_14_50\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"7f860f7d\" data-field-span=\"12\"><label id='gfield_label_14_50' class='gfield_label gform-field-label' for='gform_browse_button_14_50'><span class='gform-field-label__text'>Allega Prescrizione Medica \/ Lettera di Dimissione<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_14_50' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_14_50&quot;,&quot;container&quot;:&quot;gform_multifile_upload_14_50&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_14_50&quot;,&quot;filelist&quot;:&quot;gform_preview_14_50&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.medelit.com\\\/dott\\\/?gf_page=8f90a311dee1416&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.medelit.com\\\/dott\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.medelit.com\\\/dott\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;File consentiti&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;35840000b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:14,&quot;field_id&quot;:50,&quot;_gform_file_upload_nonce_14_50&quot;:&quot;dc9a0d31d4&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_14_50&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_14_50' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Trascina i file qui oppure <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_14_50' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_14_50 gfield_description_14_50\"  >Seleziona i file<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_14_50'>Dimensione max del file: 34 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_14_50'><\/ul> <div id='gform_preview_14_50' class='ginput_preview_list'><\/div><\/div><div class='gfield_description' id='gfield_description_14_50'>ATTENZIONE!\nPer poter accedere a questo servizio \u00e8 necessaria una lettera di invio del medico oppure prescrizione del curante oppure una lettera di dimissioni ospedaliere.\nLa lettera deve:\n- essere datata entro gli ultimi 6 mesi,\n- essere leggibile, redatta su carta intestata e riportare tutti i recapiti dello studio medico o della struttura ospedaliera,\n- contenere informazioni sulla storia clinica del paziente, sull\u2019indicazione all\u2019esecuzione del servizio richiesto e sulle attivit\u00e0 da svolgere da parte del professionista.\nIn caso di somministrazione farmaci, la prescrizione deve specificare:\n- Il nome del farmaco da somministrare\n- il dosaggio e posologia \n- Il metodo di somministrazione (inclusa via di somministrazione, ed eventuale diluizione e alla velocit\u00e0 di somministrazione per le flebo ove indicato).\n<\/div><\/div><div id=\"field_14_145\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"589b687d\" data-field-span=\"12\"><label id='gfield_label_14_145' class='gfield_label gform-field-label' for='gform_browse_button_14_145'><span class='gform-field-label__text'>Allega Prescrizione Medica<\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_14_145' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_14_145&quot;,&quot;container&quot;:&quot;gform_multifile_upload_14_145&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_14_145&quot;,&quot;filelist&quot;:&quot;gform_preview_14_145&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.medelit.com\\\/dott\\\/?gf_page=8f90a311dee1416&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.medelit.com\\\/dott\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.medelit.com\\\/dott\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;File consentiti&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;35840000b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:14,&quot;field_id&quot;:145,&quot;_gform_file_upload_nonce_14_145&quot;:&quot;936723384b&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_14_145&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_14_145' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Trascina i file qui oppure <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_14_145' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_14_145 gfield_description_14_145\"  >Seleziona i file<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_14_145'>Dimensione max del file: 34 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_14_145'><\/ul> <div id='gform_preview_14_145' class='ginput_preview_list'><\/div><\/div><div class='gfield_description' id='gfield_description_14_145'>ATTENZIONE! \nPer il servizio richiesto \u00e8 necessaria una ricetta\/ prescrizione medica valida, che deve essere:\n- Datata entro gli ultimi 6 mesi\n- Rilasciata su carta intestata, completa di tutti i dettagli e recapiti del medico\n- Firmata da un medico registrato a abilitato nell\u2019UE\n\nIn caso di somministrazione farmaci, la prescrizione deve specificare:\n- Il nome del farmaco da somministrare\n- il dosaggio e posologia \n- Il metodo di somministrazione (inclusa via di somministrazione, ed eventuale diluizione e alla velocit\u00e0 di somministrazione per le flebo ove indicato).\n<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_14_140' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Precedente<\/button> <button type='button' id='gform_next_button_14_140' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Successivo<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_14_9' class='gform_page' data-js='page-field-id-140' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_14_9' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><div id=\"field_14_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"4fc5aad2\" data-field-span=\"12\"><label id='gfield_label_14_17' class='gfield_label gform-field-label' for='input_14_17'><span class='gform-field-label__text'>Citofono<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_14_17' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_150\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"7c5f99e0\" data-field-span=\"12\"><label id='gfield_label_14_150' class='gfield_label gform-field-label' for='input_14_150'><span class='gform-field-label__text'>Interno<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_150' id='input_14_150' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"1644c1dc\" data-field-span=\"12\"><label id='gfield_label_14_18' class='gfield_label gform-field-label' for='input_14_18'><span class='gform-field-label__text'>Piano<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_14_18' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"48ba40a5\" data-field-span=\"12\"><legend id='gfield_label_14_27' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>L&#039;indirizzo Fatturazione \u00e8 uguale a quello di Visita?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_27'>\n\t\t\t<div class='gchoice gchoice_14_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Si'  id='choice_14_27_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_14_27_0 gfield_label_14_27\"   \/>\n\t\t\t\t\t<label for='choice_14_27_0' id='label_14_27_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='No'  id='choice_14_27_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_27_1' id='label_14_27_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_112\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"befad701\" data-field-span=\"12\"><legend id='gfield_label_14_112' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Indirizzo di Fatturazione Attuale<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_14_112' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_14_112_1_container' >\n                                        <input type='text' name='input_112.1' id='input_14_112_1' value=''    aria-required='true'    aria-labelledby=\"input_14_112_1_label gfield_label_14_112\"\/>\n                                        <label for='input_14_112_1' id='input_14_112_1_label' class='gform-field-label gform-field-label--type-sub '>Via\/piazza\/Corso<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_14_112_3_container' >\n                                    <input type='text' name='input_112.3' id='input_14_112_3' value=''    aria-required='true'    \/>\n                                    <label for='input_14_112_3' id='input_14_112_3_label' class='gform-field-label gform-field-label--type-sub '>Comune Visita<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_14_112_4_container' >\n                                        <input type='text' name='input_112.4' id='input_14_112_4' value=''      aria-required='true'    \/>\n                                        <label for='input_14_112_4' id='input_14_112_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia Visita<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_14_112_5_container' >\n                                    <input type='text' name='input_112.5' id='input_14_112_5' value=''    aria-required='true'    \/>\n                                    <label for='input_14_112_5' id='input_14_112_5_label' class='gform-field-label gform-field-label--type-sub '>CAP Visita<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_14_112_6_container' >\n                                        <select name='input_112.6' id='input_14_112_6'   aria-required='true'    ><option value='' ><\/option><option value='AF' >Afghanistan<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antartide<\/option><option value='AG' >Antigua e Barbuda<\/option><option value='SA' >Arabia Saudita<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BE' >Belgio<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BY' >Bielorussia<\/option><option value='MM' >Birmania<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius e Saba<\/option><option value='BA' >Bosnia-Erzegovina<\/option><option value='BW' >Botswana<\/option><option value='BR' >Brasile<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambogia<\/option><option value='CM' >Camerun<\/option><option value='CA' >Canada<\/option><option value='CV' >Capo Verde<\/option><option value='TD' >Chad<\/option><option value='CL' >Cile<\/option><option value='CN' >Cina<\/option><option value='CY' >Cipro<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comore<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Repubblica Democratica del<\/option><option value='KP' >Corea, (Repubblica Democratica Popolare di)<\/option><option value='KR' >Corea, Repubblica di<\/option><option value='CI' >Costa d&#039;Avorio<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croazia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='DK' >Danimarca<\/option><option value='DM' >Dominica<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egitto<\/option><option value='SV' >El Salvador<\/option><option value='AE' >Emirati Arabi Uniti<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >eSwatini<\/option><option value='ET' >Etiopia<\/option><option value='RU' >Federazione Russa<\/option><option value='FJ' >Fiji<\/option><option value='PH' >Filippine<\/option><option value='FI' >Finlandia<\/option><option value='FR' >Francia<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germania<\/option><option value='GH' >Ghana<\/option><option value='JM' >Giamaica<\/option><option value='JP' >Giappone<\/option><option value='GI' >Gibilterra<\/option><option value='DJ' >Gibuti<\/option><option value='JO' >Giordania<\/option><option value='GR' >Grecia<\/option><option value='GD' >Grenada<\/option><option value='GL' >Groenlandia<\/option><option value='GP' >Guadalupa<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GF' >Guiana Francese<\/option><option value='GN' >Guinea<\/option><option value='GQ' >Guinea Equatoriale<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Irlanda<\/option><option value='IS' >Islanda<\/option><option value='BV' >Isola di Bouvet<\/option><option value='IM' >Isola di Man<\/option><option value='CX' >Isola di Natale<\/option><option value='BL' >Isola di Saint Barth\u00e9lemy<\/option><option value='AX' >Isole Aland<\/option><option value='KY' >Isole Cayman<\/option><option value='CC' >Isole Cocos<\/option><option value='CK' >Isole Cook<\/option><option value='FK' >Isole Falkland<\/option><option value='FO' >Isole Faroe<\/option><option value='HM' >Isole Heard e McDonald<\/option><option value='MP' >Isole Marianne Settentrionali<\/option><option value='MH' >Isole Marshall<\/option><option value='UM' >Isole minori esterne degli Stati Uniti d&#039;America<\/option><option value='NF' >Isole Norfolk<\/option><option value='PM' >Isole Saint Pierre e Miquelon<\/option><option value='SB' >Isole Salomone<\/option><option value='SJ' >Isole Svalbard e Jan Mayen<\/option><option value='TC' >Isole Turks e Caicos<\/option><option value='VI' >Isole vergini americane<\/option><option value='VG' >Isole Vergini britanniche<\/option><option value='IL' >Israele<\/option><option value='IT' selected='selected'>Italia<\/option><option value='GS' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='KZ' >Kazakistan<\/option><option value='KE' >Kenya<\/option><option value='KG' >Kirghizistan<\/option><option value='KI' >Kiribati<\/option><option value='KW' >Kuwait<\/option><option value='LA' >Laos<\/option><option value='LS' >Lesotho<\/option><option value='LV' >Lettonia<\/option><option value='LB' >Libano<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libia<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lituania<\/option><option value='LU' >Lussemburgo<\/option><option value='MO' >Macao<\/option><option value='MK' >Macedonia del Nord<\/option><option value='MG' >Madagascar<\/option><option value='JE' >Maglia<\/option><option value='MW' >Malawi<\/option><option value='MV' >Maldive<\/option><option value='MY' >Malesia<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MA' >Marocco<\/option><option value='MQ' >Martinica<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Messico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldavia<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MZ' >Mozambico<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NO' >Norvegia<\/option><option value='NC' >Nuova Caledonia<\/option><option value='NZ' >Nuova Zelanda<\/option><option value='OM' >Oman<\/option><option value='NL' >Paesi Bassi<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua Nuova Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Polonia<\/option><option value='PF' >Polynesia Francese<\/option><option value='PR' >Porto Rico<\/option><option value='PT' >Portogallo<\/option><option value='QA' >Qatar<\/option><option value='GB' >Regno Unito<\/option><option value='SY' >Repubblica Araba di Siria<\/option><option value='CZ' >Repubblica Ceca<\/option><option value='CF' >Repubblica Centrafricana<\/option><option value='DO' >Repubblica Dominicana<\/option><option value='RE' >Riunione (Isola della)<\/option><option value='RO' >Romania<\/option><option value='RW' >Ruanda<\/option><option value='EH' >Sahara Occidentale<\/option><option value='KN' >Saint Kitts e Nevis<\/option><option value='VC' >Saint Vincent e Grenadine<\/option><option value='MF' >Saint-Martin<\/option><option value='WS' >Samoa<\/option><option value='AS' >Samoa americane<\/option><option value='SM' >San Marino<\/option><option value='SH' >Sant&#039;Elena, Ascensione e Tristan da Cunha<\/option><option value='LC' >Santa Lucia<\/option><option value='ST' >Sao Tome e Pr\u00edncipe<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SX' >Sint Maarten<\/option><option value='SK' >Slovacchia<\/option><option value='SI' >Slovenia<\/option><option value='SO' >Somalia<\/option><option value='ES' >Spagna<\/option><option value='LK' >Sri Lanka<\/option><option value='US' >Stati Uniti<\/option><option value='PS' >Stato della Palestina<\/option><option value='ZA' >Sudafrica<\/option><option value='SD' >Sudan<\/option><option value='SS' >Sudan del Sud<\/option><option value='SR' >Suriname<\/option><option value='SE' >Svezia<\/option><option value='CH' >Svizzera<\/option><option value='TJ' >Tagikistan<\/option><option value='TW' >Taiwan<\/option><option value='TZ' >Tanzania (Repubblica Unita della)<\/option><option value='TF' >Territori Meridionali Francesi<\/option><option value='IO' >Territorio Britannico nell&#039;Oceano Indiano<\/option><option value='TH' >Thailandia<\/option><option value='TL' >Timor Est<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad e Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turchia<\/option><option value='TM' >Turkmenistan<\/option><option value='TV' >Tuvalu<\/option><option value='UA' >Ucraina<\/option><option value='UG' >Uganda<\/option><option value='HU' >Ungheria<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vaticano (Santa Sede)<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis e Futuna<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select>\n                                        <label for='input_14_112_6' id='input_14_112_6_label' class='gform-field-label gform-field-label--type-sub '>Nazione<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><input type=\"hidden\" name=\"gpaa_place_112\" class=\"gform_hidden\" value=\"\"><\/fieldset><fieldset id=\"field_14_172\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"233e0fb4\" data-field-span=\"12\"><legend id='gfield_label_14_172' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>SYSTEM Invoicing Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_14_172' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_14_172_1_container' >\n                                        <input readonly='readonly' type='text' name='input_172.1' id='input_14_172_1' value=''    aria-required='true'    aria-labelledby=\"input_14_172_1_label gfield_label_14_172\"\/>\n                                        <label for='input_14_172_1' id='input_14_172_1_label' class='gform-field-label gform-field-label--type-sub '>Via\/piazza\/Corso<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_14_172_3_container' >\n                                    <input readonly='readonly' type='text' name='input_172.3' id='input_14_172_3' value=''    aria-required='true'    \/>\n                                    <label for='input_14_172_3' id='input_14_172_3_label' class='gform-field-label gform-field-label--type-sub '>Comune Visita<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_14_172_4_container' >\n                                        <input readonly='readonly' type='text' name='input_172.4' id='input_14_172_4' value=''      aria-required='true'    \/>\n                                        <label for='input_14_172_4' id='input_14_172_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia Visita<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_14_172_5_container' >\n                                    <input readonly='readonly' type='text' name='input_172.5' id='input_14_172_5' value=''    aria-required='true'    \/>\n                                    <label for='input_14_172_5' id='input_14_172_5_label' class='gform-field-label gform-field-label--type-sub '>CAP Visita<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_14_172_6_container' >\n                                        <select class='gf-default-disabled' disabled='disabled' name='input_172.6' id='input_14_172_6'   aria-required='true'    ><option value='' ><\/option><option value='AF' >Afghanistan<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antartide<\/option><option value='AG' >Antigua e Barbuda<\/option><option value='SA' >Arabia Saudita<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BE' >Belgio<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BY' >Bielorussia<\/option><option value='MM' >Birmania<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius e Saba<\/option><option value='BA' >Bosnia-Erzegovina<\/option><option value='BW' >Botswana<\/option><option value='BR' >Brasile<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambogia<\/option><option value='CM' >Camerun<\/option><option value='CA' >Canada<\/option><option value='CV' >Capo Verde<\/option><option value='TD' >Chad<\/option><option value='CL' >Cile<\/option><option value='CN' >Cina<\/option><option value='CY' >Cipro<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comore<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Repubblica Democratica del<\/option><option value='KP' >Corea, (Repubblica Democratica Popolare di)<\/option><option value='KR' >Corea, Repubblica di<\/option><option value='CI' >Costa d&#039;Avorio<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croazia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='DK' >Danimarca<\/option><option value='DM' >Dominica<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egitto<\/option><option value='SV' >El Salvador<\/option><option value='AE' >Emirati Arabi Uniti<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >eSwatini<\/option><option value='ET' >Etiopia<\/option><option value='RU' >Federazione Russa<\/option><option value='FJ' >Fiji<\/option><option value='PH' >Filippine<\/option><option value='FI' >Finlandia<\/option><option value='FR' >Francia<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germania<\/option><option value='GH' >Ghana<\/option><option value='JM' >Giamaica<\/option><option value='JP' >Giappone<\/option><option value='GI' >Gibilterra<\/option><option value='DJ' >Gibuti<\/option><option value='JO' >Giordania<\/option><option value='GR' >Grecia<\/option><option value='GD' >Grenada<\/option><option value='GL' >Groenlandia<\/option><option value='GP' >Guadalupa<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GF' >Guiana Francese<\/option><option value='GN' >Guinea<\/option><option value='GQ' >Guinea Equatoriale<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Irlanda<\/option><option value='IS' >Islanda<\/option><option value='BV' >Isola di Bouvet<\/option><option value='IM' >Isola di Man<\/option><option value='CX' >Isola di Natale<\/option><option value='BL' >Isola di Saint Barth\u00e9lemy<\/option><option value='AX' >Isole Aland<\/option><option value='KY' >Isole Cayman<\/option><option value='CC' >Isole Cocos<\/option><option value='CK' >Isole Cook<\/option><option value='FK' >Isole Falkland<\/option><option value='FO' >Isole Faroe<\/option><option value='HM' >Isole Heard e McDonald<\/option><option value='MP' >Isole Marianne Settentrionali<\/option><option value='MH' >Isole Marshall<\/option><option value='UM' >Isole minori esterne degli Stati Uniti d&#039;America<\/option><option value='NF' >Isole Norfolk<\/option><option value='PM' >Isole Saint Pierre e Miquelon<\/option><option value='SB' >Isole Salomone<\/option><option value='SJ' >Isole Svalbard e Jan Mayen<\/option><option value='TC' >Isole Turks e Caicos<\/option><option value='VI' >Isole vergini americane<\/option><option value='VG' >Isole Vergini britanniche<\/option><option value='IL' >Israele<\/option><option value='IT' selected='selected'>Italia<\/option><option value='GS' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='KZ' >Kazakistan<\/option><option value='KE' >Kenya<\/option><option value='KG' >Kirghizistan<\/option><option value='KI' >Kiribati<\/option><option value='KW' >Kuwait<\/option><option value='LA' >Laos<\/option><option value='LS' >Lesotho<\/option><option value='LV' >Lettonia<\/option><option value='LB' >Libano<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libia<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lituania<\/option><option value='LU' >Lussemburgo<\/option><option value='MO' >Macao<\/option><option value='MK' >Macedonia del Nord<\/option><option value='MG' >Madagascar<\/option><option value='JE' >Maglia<\/option><option value='MW' >Malawi<\/option><option value='MV' >Maldive<\/option><option value='MY' >Malesia<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MA' >Marocco<\/option><option value='MQ' >Martinica<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Messico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldavia<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MZ' >Mozambico<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NO' >Norvegia<\/option><option value='NC' >Nuova Caledonia<\/option><option value='NZ' >Nuova Zelanda<\/option><option value='OM' >Oman<\/option><option value='NL' >Paesi Bassi<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua Nuova Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Polonia<\/option><option value='PF' >Polynesia Francese<\/option><option value='PR' >Porto Rico<\/option><option value='PT' >Portogallo<\/option><option value='QA' >Qatar<\/option><option value='GB' >Regno Unito<\/option><option value='SY' >Repubblica Araba di Siria<\/option><option value='CZ' >Repubblica Ceca<\/option><option value='CF' >Repubblica Centrafricana<\/option><option value='DO' >Repubblica Dominicana<\/option><option value='RE' >Riunione (Isola della)<\/option><option value='RO' >Romania<\/option><option value='RW' >Ruanda<\/option><option value='EH' >Sahara Occidentale<\/option><option value='KN' >Saint Kitts e Nevis<\/option><option value='VC' >Saint Vincent e Grenadine<\/option><option value='MF' >Saint-Martin<\/option><option value='WS' >Samoa<\/option><option value='AS' >Samoa americane<\/option><option value='SM' >San Marino<\/option><option value='SH' >Sant&#039;Elena, Ascensione e Tristan da Cunha<\/option><option value='LC' >Santa Lucia<\/option><option value='ST' >Sao Tome e Pr\u00edncipe<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SX' >Sint Maarten<\/option><option value='SK' >Slovacchia<\/option><option value='SI' >Slovenia<\/option><option value='SO' >Somalia<\/option><option value='ES' >Spagna<\/option><option value='LK' >Sri Lanka<\/option><option value='US' >Stati Uniti<\/option><option value='PS' >Stato della Palestina<\/option><option value='ZA' >Sudafrica<\/option><option value='SD' >Sudan<\/option><option value='SS' >Sudan del Sud<\/option><option value='SR' >Suriname<\/option><option value='SE' >Svezia<\/option><option value='CH' >Svizzera<\/option><option value='TJ' >Tagikistan<\/option><option value='TW' >Taiwan<\/option><option value='TZ' >Tanzania (Repubblica Unita della)<\/option><option value='TF' >Territori Meridionali Francesi<\/option><option value='IO' >Territorio Britannico nell&#039;Oceano Indiano<\/option><option value='TH' >Thailandia<\/option><option value='TL' >Timor Est<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad e Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turchia<\/option><option value='TM' >Turkmenistan<\/option><option value='TV' >Tuvalu<\/option><option value='UA' >Ucraina<\/option><option value='UG' >Uganda<\/option><option value='HU' >Ungheria<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vaticano (Santa Sede)<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis e Futuna<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select>\n                                        <label for='input_14_172_6' id='input_14_172_6_label' class='gform-field-label gform-field-label--type-sub '>Nazione<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <input type=\"hidden\" id=\"gwro_hidden_capture_14_172_6\" name=\"gwro_hidden_capture_14_172_6\" value=\"\" class=\"gf-default-disabled\" \/><\/div><input type=\"hidden\" name=\"gpaa_place_172\" class=\"gform_hidden\" value=\"\"><\/fieldset><fieldset id=\"field_14_28\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"7c03a424\" data-field-span=\"12\"><legend id='gfield_label_14_28' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Indirizzo Fattura<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_14_28' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_14_28_1_container' >\n                                        <input type='text' name='input_28.1' id='input_14_28_1' value=''    aria-required='true'    aria-labelledby=\"input_14_28_1_label gfield_label_14_28\"\/>\n                                        <label for='input_14_28_1' id='input_14_28_1_label' class='gform-field-label gform-field-label--type-sub '>Via\/Piazza\/Corso e numero civico<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_14_28_3_container' >\n                                    <input type='text' name='input_28.3' id='input_14_28_3' value=''    aria-required='true'    \/>\n                                    <label for='input_14_28_3' id='input_14_28_3_label' class='gform-field-label gform-field-label--type-sub '>Localit\u00e0<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_14_28_4_container' >\n                                        <input type='text' name='input_28.4' id='input_14_28_4' value=''      aria-required='true'    \/>\n                                        <label for='input_14_28_4' id='input_14_28_4_label' class='gform-field-label gform-field-label--type-sub '>Stato \/ Provincia \/ Regione<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_14_28_5_container' >\n                                    <input type='text' name='input_28.5' id='input_14_28_5' value=''    aria-required='true'    \/>\n                                    <label for='input_14_28_5' id='input_14_28_5_label' class='gform-field-label gform-field-label--type-sub '>CAP \/ Codice postale<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_14_28_6_container' >\n                                        <select name='input_28.6' id='input_14_28_6'   aria-required='true'    ><option value='' ><\/option><option value='AF' >Afghanistan<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antartide<\/option><option value='AG' >Antigua e Barbuda<\/option><option value='SA' >Arabia Saudita<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BE' >Belgio<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BY' >Bielorussia<\/option><option value='MM' >Birmania<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius e Saba<\/option><option value='BA' >Bosnia-Erzegovina<\/option><option value='BW' >Botswana<\/option><option value='BR' >Brasile<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambogia<\/option><option value='CM' >Camerun<\/option><option value='CA' >Canada<\/option><option value='CV' >Capo Verde<\/option><option value='TD' >Chad<\/option><option value='CL' >Cile<\/option><option value='CN' >Cina<\/option><option value='CY' >Cipro<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comore<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Repubblica Democratica del<\/option><option value='KP' >Corea, (Repubblica Democratica Popolare di)<\/option><option value='KR' >Corea, Repubblica di<\/option><option value='CI' >Costa d&#039;Avorio<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croazia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='DK' >Danimarca<\/option><option value='DM' >Dominica<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egitto<\/option><option value='SV' >El Salvador<\/option><option value='AE' >Emirati Arabi Uniti<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >eSwatini<\/option><option value='ET' >Etiopia<\/option><option value='RU' >Federazione Russa<\/option><option value='FJ' >Fiji<\/option><option value='PH' >Filippine<\/option><option value='FI' >Finlandia<\/option><option value='FR' >Francia<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germania<\/option><option value='GH' >Ghana<\/option><option value='JM' >Giamaica<\/option><option value='JP' >Giappone<\/option><option value='GI' >Gibilterra<\/option><option value='DJ' >Gibuti<\/option><option value='JO' >Giordania<\/option><option value='GR' >Grecia<\/option><option value='GD' >Grenada<\/option><option value='GL' >Groenlandia<\/option><option value='GP' >Guadalupa<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GF' >Guiana Francese<\/option><option value='GN' >Guinea<\/option><option value='GQ' >Guinea Equatoriale<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Irlanda<\/option><option value='IS' >Islanda<\/option><option value='BV' >Isola di Bouvet<\/option><option value='IM' >Isola di Man<\/option><option value='CX' >Isola di Natale<\/option><option value='BL' >Isola di Saint Barth\u00e9lemy<\/option><option value='AX' >Isole Aland<\/option><option value='KY' >Isole Cayman<\/option><option value='CC' >Isole Cocos<\/option><option value='CK' >Isole Cook<\/option><option value='FK' >Isole Falkland<\/option><option value='FO' >Isole Faroe<\/option><option value='HM' >Isole Heard e McDonald<\/option><option value='MP' >Isole Marianne Settentrionali<\/option><option value='MH' >Isole Marshall<\/option><option value='UM' >Isole minori esterne degli Stati Uniti d&#039;America<\/option><option value='NF' >Isole Norfolk<\/option><option value='PM' >Isole Saint Pierre e Miquelon<\/option><option value='SB' >Isole Salomone<\/option><option value='SJ' >Isole Svalbard e Jan Mayen<\/option><option value='TC' >Isole Turks e Caicos<\/option><option value='VI' >Isole vergini americane<\/option><option value='VG' >Isole Vergini britanniche<\/option><option value='IL' >Israele<\/option><option value='IT' selected='selected'>Italia<\/option><option value='GS' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='KZ' >Kazakistan<\/option><option value='KE' >Kenya<\/option><option value='KG' >Kirghizistan<\/option><option value='KI' >Kiribati<\/option><option value='KW' >Kuwait<\/option><option value='LA' >Laos<\/option><option value='LS' >Lesotho<\/option><option value='LV' >Lettonia<\/option><option value='LB' >Libano<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libia<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lituania<\/option><option value='LU' >Lussemburgo<\/option><option value='MO' >Macao<\/option><option value='MK' >Macedonia del Nord<\/option><option value='MG' >Madagascar<\/option><option value='JE' >Maglia<\/option><option value='MW' >Malawi<\/option><option value='MV' >Maldive<\/option><option value='MY' >Malesia<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MA' >Marocco<\/option><option value='MQ' >Martinica<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Messico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldavia<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MZ' >Mozambico<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NO' >Norvegia<\/option><option value='NC' >Nuova Caledonia<\/option><option value='NZ' >Nuova Zelanda<\/option><option value='OM' >Oman<\/option><option value='NL' >Paesi Bassi<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua Nuova Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Polonia<\/option><option value='PF' >Polynesia Francese<\/option><option value='PR' >Porto Rico<\/option><option value='PT' >Portogallo<\/option><option value='QA' >Qatar<\/option><option value='GB' >Regno Unito<\/option><option value='SY' >Repubblica Araba di Siria<\/option><option value='CZ' >Repubblica Ceca<\/option><option value='CF' >Repubblica Centrafricana<\/option><option value='DO' >Repubblica Dominicana<\/option><option value='RE' >Riunione (Isola della)<\/option><option value='RO' >Romania<\/option><option value='RW' >Ruanda<\/option><option value='EH' >Sahara Occidentale<\/option><option value='KN' >Saint Kitts e Nevis<\/option><option value='VC' >Saint Vincent e Grenadine<\/option><option value='MF' >Saint-Martin<\/option><option value='WS' >Samoa<\/option><option value='AS' >Samoa americane<\/option><option value='SM' >San Marino<\/option><option value='SH' >Sant&#039;Elena, Ascensione e Tristan da Cunha<\/option><option value='LC' >Santa Lucia<\/option><option value='ST' >Sao Tome e Pr\u00edncipe<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SX' >Sint Maarten<\/option><option value='SK' >Slovacchia<\/option><option value='SI' >Slovenia<\/option><option value='SO' >Somalia<\/option><option value='ES' >Spagna<\/option><option value='LK' >Sri Lanka<\/option><option value='US' >Stati Uniti<\/option><option value='PS' >Stato della Palestina<\/option><option value='ZA' >Sudafrica<\/option><option value='SD' >Sudan<\/option><option value='SS' >Sudan del Sud<\/option><option value='SR' >Suriname<\/option><option value='SE' >Svezia<\/option><option value='CH' >Svizzera<\/option><option value='TJ' >Tagikistan<\/option><option value='TW' >Taiwan<\/option><option value='TZ' >Tanzania (Repubblica Unita della)<\/option><option value='TF' >Territori Meridionali Francesi<\/option><option value='IO' >Territorio Britannico nell&#039;Oceano Indiano<\/option><option value='TH' >Thailandia<\/option><option value='TL' >Timor Est<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad e Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turchia<\/option><option value='TM' >Turkmenistan<\/option><option value='TV' >Tuvalu<\/option><option value='UA' >Ucraina<\/option><option value='UG' >Uganda<\/option><option value='HU' >Ungheria<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vaticano (Santa Sede)<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis e Futuna<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select>\n                                        <label for='input_14_28_6' id='input_14_28_6_label' class='gform-field-label gform-field-label--type-sub '>Nazione<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><input type=\"hidden\" name=\"gpaa_place_28\" class=\"gform_hidden\" value=\"\"><\/fieldset><fieldset id=\"field_14_29\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"a2482a08\" data-field-span=\"12\"><legend id='gfield_label_14_29' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Indirizzo Residenza Fiscale<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_state has_zip has_country ginput_container_address gform-grid-row' id='input_14_29' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_14_29_1_container' >\n                                        <input type='text' name='input_29.1' id='input_14_29_1' value=''    aria-required='true'    aria-labelledby=\"input_14_29_1_label gfield_label_14_29\"\/>\n                                        <label for='input_14_29_1' id='input_14_29_1_label' class='gform-field-label gform-field-label--type-sub '>Via Piazza\/Corso<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_14_29_2_container' >\n                                        <input type='text' name='input_29.2' id='input_14_29_2' value=''     aria-required='false'   \/>\n                                        <label for='input_14_29_2' id='input_14_29_2_label' class='gform-field-label gform-field-label--type-sub '>Numero Civico<\/label>\n                                    <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_14_29_4_container' >\n                                        <input type='text' name='input_29.4' id='input_14_29_4' value=''      aria-required='true'    \/>\n                                        <label for='input_14_29_4' id='input_14_29_4_label' class='gform-field-label gform-field-label--type-sub '>Stato \/ Provincia \/ Regione<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_14_29_5_container' >\n                                    <input type='text' name='input_29.5' id='input_14_29_5' value=''    aria-required='true'    \/>\n                                    <label for='input_14_29_5' id='input_14_29_5_label' class='gform-field-label gform-field-label--type-sub '>CAP \/ Codice postale<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_14_29_6_container' >\n                                        <select name='input_29.6' id='input_14_29_6'   aria-required='true'    ><option value='' ><\/option><option value='AF' >Afghanistan<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antartide<\/option><option value='AG' >Antigua e Barbuda<\/option><option value='SA' >Arabia Saudita<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BE' >Belgio<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BY' >Bielorussia<\/option><option value='MM' >Birmania<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius e Saba<\/option><option value='BA' >Bosnia-Erzegovina<\/option><option value='BW' >Botswana<\/option><option value='BR' >Brasile<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambogia<\/option><option value='CM' >Camerun<\/option><option value='CA' >Canada<\/option><option value='CV' >Capo Verde<\/option><option value='TD' >Chad<\/option><option value='CL' >Cile<\/option><option value='CN' >Cina<\/option><option value='CY' >Cipro<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comore<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Repubblica Democratica del<\/option><option value='KP' >Corea, (Repubblica Democratica Popolare di)<\/option><option value='KR' >Corea, Repubblica di<\/option><option value='CI' >Costa d&#039;Avorio<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croazia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='DK' >Danimarca<\/option><option value='DM' >Dominica<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egitto<\/option><option value='SV' >El Salvador<\/option><option value='AE' >Emirati Arabi Uniti<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >eSwatini<\/option><option value='ET' >Etiopia<\/option><option value='RU' >Federazione Russa<\/option><option value='FJ' >Fiji<\/option><option value='PH' >Filippine<\/option><option value='FI' >Finlandia<\/option><option value='FR' >Francia<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germania<\/option><option value='GH' >Ghana<\/option><option value='JM' >Giamaica<\/option><option value='JP' >Giappone<\/option><option value='GI' >Gibilterra<\/option><option value='DJ' >Gibuti<\/option><option value='JO' >Giordania<\/option><option value='GR' >Grecia<\/option><option value='GD' >Grenada<\/option><option value='GL' >Groenlandia<\/option><option value='GP' >Guadalupa<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GF' >Guiana Francese<\/option><option value='GN' >Guinea<\/option><option value='GQ' >Guinea Equatoriale<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Irlanda<\/option><option value='IS' >Islanda<\/option><option value='BV' >Isola di Bouvet<\/option><option value='IM' >Isola di Man<\/option><option value='CX' >Isola di Natale<\/option><option value='BL' >Isola di Saint Barth\u00e9lemy<\/option><option value='AX' >Isole Aland<\/option><option value='KY' >Isole Cayman<\/option><option value='CC' >Isole Cocos<\/option><option value='CK' >Isole Cook<\/option><option value='FK' >Isole Falkland<\/option><option value='FO' >Isole Faroe<\/option><option value='HM' >Isole Heard e McDonald<\/option><option value='MP' >Isole Marianne Settentrionali<\/option><option value='MH' >Isole Marshall<\/option><option value='UM' >Isole minori esterne degli Stati Uniti d&#039;America<\/option><option value='NF' >Isole Norfolk<\/option><option value='PM' >Isole Saint Pierre e Miquelon<\/option><option value='SB' >Isole Salomone<\/option><option value='SJ' >Isole Svalbard e Jan Mayen<\/option><option value='TC' >Isole Turks e Caicos<\/option><option value='VI' >Isole vergini americane<\/option><option value='VG' >Isole Vergini britanniche<\/option><option value='IL' >Israele<\/option><option value='IT' selected='selected'>Italia<\/option><option value='GS' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='KZ' >Kazakistan<\/option><option value='KE' >Kenya<\/option><option value='KG' >Kirghizistan<\/option><option value='KI' >Kiribati<\/option><option value='KW' >Kuwait<\/option><option value='LA' >Laos<\/option><option value='LS' >Lesotho<\/option><option value='LV' >Lettonia<\/option><option value='LB' >Libano<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libia<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lituania<\/option><option value='LU' >Lussemburgo<\/option><option value='MO' >Macao<\/option><option value='MK' >Macedonia del Nord<\/option><option value='MG' >Madagascar<\/option><option value='JE' >Maglia<\/option><option value='MW' >Malawi<\/option><option value='MV' >Maldive<\/option><option value='MY' >Malesia<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MA' >Marocco<\/option><option value='MQ' >Martinica<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Messico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldavia<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MZ' >Mozambico<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NO' >Norvegia<\/option><option value='NC' >Nuova Caledonia<\/option><option value='NZ' >Nuova Zelanda<\/option><option value='OM' >Oman<\/option><option value='NL' >Paesi Bassi<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua Nuova Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Polonia<\/option><option value='PF' >Polynesia Francese<\/option><option value='PR' >Porto Rico<\/option><option value='PT' >Portogallo<\/option><option value='QA' >Qatar<\/option><option value='GB' >Regno Unito<\/option><option value='SY' >Repubblica Araba di Siria<\/option><option value='CZ' >Repubblica Ceca<\/option><option value='CF' >Repubblica Centrafricana<\/option><option value='DO' >Repubblica Dominicana<\/option><option value='RE' >Riunione (Isola della)<\/option><option value='RO' >Romania<\/option><option value='RW' >Ruanda<\/option><option value='EH' >Sahara Occidentale<\/option><option value='KN' >Saint Kitts e Nevis<\/option><option value='VC' >Saint Vincent e Grenadine<\/option><option value='MF' >Saint-Martin<\/option><option value='WS' >Samoa<\/option><option value='AS' >Samoa americane<\/option><option value='SM' >San Marino<\/option><option value='SH' >Sant&#039;Elena, Ascensione e Tristan da Cunha<\/option><option value='LC' >Santa Lucia<\/option><option value='ST' >Sao Tome e Pr\u00edncipe<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SX' >Sint Maarten<\/option><option value='SK' >Slovacchia<\/option><option value='SI' >Slovenia<\/option><option value='SO' >Somalia<\/option><option value='ES' >Spagna<\/option><option value='LK' >Sri Lanka<\/option><option value='US' >Stati Uniti<\/option><option value='PS' >Stato della Palestina<\/option><option value='ZA' >Sudafrica<\/option><option value='SD' >Sudan<\/option><option value='SS' >Sudan del Sud<\/option><option value='SR' >Suriname<\/option><option value='SE' >Svezia<\/option><option value='CH' >Svizzera<\/option><option value='TJ' >Tagikistan<\/option><option value='TW' >Taiwan<\/option><option value='TZ' >Tanzania (Repubblica Unita della)<\/option><option value='TF' >Territori Meridionali Francesi<\/option><option value='IO' >Territorio Britannico nell&#039;Oceano Indiano<\/option><option value='TH' >Thailandia<\/option><option value='TL' >Timor Est<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad e Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turchia<\/option><option value='TM' >Turkmenistan<\/option><option value='TV' >Tuvalu<\/option><option value='UA' >Ucraina<\/option><option value='UG' >Uganda<\/option><option value='HU' >Ungheria<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vaticano (Santa Sede)<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis e Futuna<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select>\n                                        <label for='input_14_29_6' id='input_14_29_6_label' class='gform-field-label gform-field-label--type-sub '>Nazione<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><input type=\"hidden\" name=\"gpaa_place_29\" class=\"gform_hidden\" value=\"\"><\/fieldset><div id=\"field_14_104\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"e434bf23\" data-field-span=\"12\"><label id='gfield_label_14_104' class='gfield_label gform-field-label' for='input_14_104'><span class='gform-field-label__text'>Il Suo Citofono<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_104' id='input_14_104' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_149\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"30d1b98b\" data-field-span=\"12\"><label id='gfield_label_14_149' class='gfield_label gform-field-label' for='input_14_149'><span class='gform-field-label__text'>Il Suo Interno<\/span><\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_149' id='input_14_149' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_105\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"ba059a68\" data-field-span=\"12\"><label id='gfield_label_14_105' class='gfield_label gform-field-label' for='input_14_105'><span class='gform-field-label__text'>Il suo Piano Abitazione<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_105' id='input_14_105' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"99d671aa\" data-field-span=\"12\"><legend id='gfield_label_14_32' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Ha una copertura assicurativa?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_32'>\n\t\t\t<div class='gchoice gchoice_14_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='No'  id='choice_14_32_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_14_32_0 gfield_label_14_32\"   \/>\n\t\t\t\t\t<label for='choice_14_32_0' id='label_14_32_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Si'  id='choice_14_32_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_32_1' id='label_14_32_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"bbfbcb66\" data-field-span=\"12\"><legend id='gfield_label_14_33' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Come Preferisce eseguire il Pagamento della Prenotazione?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_33'>\n\t\t\t<div class='gchoice gchoice_14_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Carta di Credito\/Debit Card'  id='choice_14_33_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_14_33\" aria-labelledby=\"label_14_33_0 gfield_label_14_33\"   \/>\n\t\t\t\t\t<label for='choice_14_33_0' id='label_14_33_0' class='gform-field-label gform-field-label--type-inline'>Carta di Credito\/Debit Card<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Postepay\/Prepagata'  id='choice_14_33_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_33_1' id='label_14_33_1' class='gform-field-label gform-field-label--type-inline'>Postepay\/Prepagata<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_33_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Bonifico'  id='choice_14_33_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_33_2' id='label_14_33_2' class='gform-field-label gform-field-label--type-inline'>Bonifico<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_33_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Paypal'  id='choice_14_33_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_33_3' id='label_14_33_3' class='gform-field-label gform-field-label--type-inline'>Paypal<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_14_33'>NB. NON accettiamo pagamenti in contanti o Bancomat. Le video consulenze possono essere pagate unicamente con carta di credito oppure Paypal.\nIl pagamento con Paypal prevede una lieve maggiorazione della tariffa a copertura delle commissioni.\nPer il pagamento con BONIFICO occorrer\u00e0 inviare copia della distinta di pagamento.<\/div><\/fieldset><div id=\"field_14_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"351706d6\" data-field-span=\"12\"><label id='gfield_label_14_51' class='gfield_label gform-field-label' for='input_14_51'><span class='gform-field-label__text'>Ha un CODICE SCONTO? Ce lo scriva qui!<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_14_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_14_79' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Precedente<\/button> <button type='button' id='gform_next_button_14_79' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Successivo<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_14_10' class='gform_page' data-js='page-field-id-79' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_14_10' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><fieldset id=\"field_14_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"d26d10a7\" data-field-span=\"12\"><legend id='gfield_label_14_37' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Chi sta compilando questa prenotazione?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_37'>\n\t\t\t<div class='gchoice gchoice_14_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Sono la persona da visitare'  id='choice_14_37_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_14_37_0 gfield_label_14_37\"   \/>\n\t\t\t\t\t<label for='choice_14_37_0' id='label_14_37_0' class='gform-field-label gform-field-label--type-inline'>Sono la persona da visitare<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Sto compilando la richiesta per conto del Paziente'  id='choice_14_37_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_37_1' id='label_14_37_1' class='gform-field-label gform-field-label--type-inline'>Sto compilando la richiesta per conto del Paziente<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"5df74cce\" data-field-span=\"12\"><legend id='gfield_label_14_38' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Ha il consenso del Paziente per fornirci i dati e per Richiedere la Visita?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_38'>\n\t\t\t<div class='gchoice gchoice_14_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Si, ho ricevuto il consenso da parte del Paziente'  id='choice_14_38_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_14_38\" aria-labelledby=\"label_14_38_0 gfield_label_14_38\"   \/>\n\t\t\t\t\t<label for='choice_14_38_0' id='label_14_38_0' class='gform-field-label gform-field-label--type-inline'>Si, ho ricevuto il consenso da parte del Paziente<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Sono il Tutore Legale\/Amministratore di Sostegno del Paziente'  id='choice_14_38_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_38_1' id='label_14_38_1' class='gform-field-label gform-field-label--type-inline'>Sono il Tutore Legale\/Amministratore di Sostegno del Paziente<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_38_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Non ho alcun consenso da parte del paziente'  id='choice_14_38_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_14_38_2' id='label_14_38_2' class='gform-field-label gform-field-label--type-inline'>Non ho alcun consenso da parte del paziente<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_14_38'>Se NON \u00e8 la persona che dobbiamo visitare e non ha il suo esplicito consenso, pu\u00f2 prenotare e fornire il consenso SOLO se \u00e8 il Tutore Legale o Amministratore di Sostegno del paziente. La relativa documentazione dovr\u00e0 essere inviata insieme alla richiesta di prenotazione.<\/div><\/fieldset><div id=\"field_14_40\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"389d288a\" data-field-span=\"12\"><label id='gfield_label_14_40' class='gfield_label gform-field-label' for='input_14_40'><span class='gform-field-label__text'>Il suo Nome e Cognome<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_14_40' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_67\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"5c15485e\" data-field-span=\"12\"><h2 class=\"form-title\" style=\"text-align: justify;\"><span style=\"color: #ca1517; font-size: 16px;\">ATTENZIONE - Ci dispiace ma non possiamo procedere con la prenotazione senza il consenso del Paziente.<\/span><\/h2><\/div><div id=\"field_14_46\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"1d975925\" data-field-span=\"12\"><label id='gfield_label_14_46' class='gfield_label gform-field-label' for='gform_browse_button_14_46'><span class='gform-field-label__text'>Per favore carichi qui la Documentazione relativa a Tutore Legale \/ Amministratore di Sostegno<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_14_46' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_14_46&quot;,&quot;container&quot;:&quot;gform_multifile_upload_14_46&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_14_46&quot;,&quot;filelist&quot;:&quot;gform_preview_14_46&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.medelit.com\\\/dott\\\/?gf_page=8f90a311dee1416&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.medelit.com\\\/dott\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.medelit.com\\\/dott\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;File consentiti&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;35840000b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:14,&quot;field_id&quot;:46,&quot;_gform_file_upload_nonce_14_46&quot;:&quot;713d00d4a6&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_14_46&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_14_46' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Trascina i file qui oppure <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_14_46' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_14_46 gfield_description_14_46\"  >Seleziona i file<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_14_46'>Dimensione max del file: 34 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_14_46'><\/ul> <div id='gform_preview_14_46' class='ginput_preview_list'><\/div><\/div><div class='gfield_description' id='gfield_description_14_46'>Potremo procedere con la prenotazione solo una volta ricevuta la documentazione. Se ha difficolt\u00e0 a caricare il file, ci contatti via chat cos\u00ec da poterla assistere.<\/div><\/div><div id=\"field_14_47\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"6c03d166\" data-field-span=\"12\"><label id='gfield_label_14_47' class='gfield_label gform-field-label' for='input_14_47'><span class='gform-field-label__text'>Come \u00e8 venuto\/a a conoscenza di Medelit?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_47' id='input_14_47' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='Passaparola' >Passaparola<\/option><option value='Famigliare\/Amici' >Famigliare\/Amici<\/option><option value='Medico di base\/specialista' >Medico di base\/specialista<\/option><option value='Altro Professionista Sanitario che la Assiste' >Altro Professionista Sanitario che la Assiste<\/option><option value='Motore di Ricerca' >Motore di Ricerca<\/option><option value='Volantino' >Volantino<\/option><option value='Social Network' >Social Network<\/option><option value='Altro' >Altro<\/option><\/select><\/div><\/div><div id=\"field_14_48\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"2057fd35\" data-field-span=\"12\"><label id='gfield_label_14_48' class='gfield_label gform-field-label' for='input_14_48'><span class='gform-field-label__text'>Pu\u00f2 per favore dirci come \u00e8 venuto\/a a conoscenza di Medelit?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_14_48' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_24\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"7a8b88f0\" data-field-span=\"12\"><legend id='gfield_label_14_24' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Consenso\/Informativa Privacy<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_24.1' id='input_14_24_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_14_24\" aria-labelledby=\"input_14_24_1_label gfield_label_14_24\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label id='input_14_24_1_label' class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_14_24_1' ><span class='gform-field-label__text'>Consenso<\/span><\/label><input type='hidden' name='input_24.2' value='Consenso' class='gform_hidden' \/><input type='hidden' name='input_24.3' value='4' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_14_24'><div class='gfield_consent_description_text gform-theme__no-reset--children' tabindex='0'>Gentile Signore, Gentile Signora,<br \/>\nCome previsto dall\u2019attuale normativa GDPR in materia del trattamento dei dati, La<br \/>\ninformiamo che i dati personali, che Lei \u201cinteressato\u201d, o la persona in Sua vece dichiarante avente facolt\u00e0, vorr\u00e0 liberamente fornirci, presso di noi<br \/>\no presso il suo domicilio, saranno oggetto di trattamento secondo modalit\u00e0 di raccolta e requisiti indicati dall\u2019articolo 9, solo con il consenso<br \/>\nespresso dell\u2019interessato.<br \/>\nFinalita\u2019 E Modalit\u00e0 Del Trattamento:<br \/>\nLa informiamo che, ai sensi dell\u2019art.13 del D.Lgs. 196 del 30 Giugno 2003 e successive modifiche, i dati da Lei forniti per le prestazioni sanitarie,<br \/>\nverranno utilizzati all\u2019interno di Medelit esclusivamente ai fini dello svolgimento del processo di informazione, diagnosi e cura e per lo<br \/>\nsvolgimento delle pratiche amministrative. I dati saranno trattati in forma cartacea e\/o su supporto magnetico, elettronico o telematico, mediante<br \/>\nstrumenti idonei a garantire la sicurezza e la riservatezza degli stessi.<br \/>\nNatura obbligatoria o facoltativa del conferimento dei dati:<br \/>\nIl conferimento dei dati a Medelit \u00e8 necessario per la corretta compilazione e gestione della documentazione sanitaria e per lo svolgimento delle<br \/>\nrelative pratiche amministrative.<br \/>\nConseguenze in caso di rifiuto di conferire i dati:<br \/>\nIn caso di rifiuto al consenso del trattamento dei dati non potranno quindi essere effettuate le prestazioni sanitarie richieste o non potranno essere fornite risposte ai quesiti che lei vorr\u00e0 richiederci.<br \/>\nTutela della salute e dell\u2019incolumit\u00e0 fisica:<br \/>\nIn caso di impossibilit\u00e0 fisica, incapacit\u00e0 di agire o incapacit\u00e0 di intende o di volere, il consenso al trattamento dei dati personali potr\u00e0 essere<br \/>\nacquisito dai seguenti specificatamente individuati: Colui che esercita legalmente la potest\u00e0, prossimo congiunto, familiare, convivente,<br \/>\nresponsabile della struttura di provenienza\/degenza nel caso di assenza dei sopraccitati soggetti.<br \/>\nAmbito di comunicazione e di diffusione dei dati:<br \/>\nI suoi dati anagrafici, le indagini diagnostiche, i referti e quant\u2019altro necessario saranno comunicati, in base alle norme vigenti, dietro specifica<br \/>\nrichiesta all\u2019autorit\u00e0 giudiziaria e ad ogni altro Ente destinatario per legge o per regolamento.<br \/>\nI dati personali anagrafici potranno essere comunicati alle strutture sanitarie, ai servizi di medicina di laboratorio e a tutti gli altri enti esterni che<br \/>\nforniscono prestazioni non effettuate da Medelit, alle casse mutue, agli enti di assicurazione e assimilabili, ai soggetti operanti presso Medelit e ove<br \/>\nnecessario studi legali e partners assicurativi. La volont\u00e0 di non comunicare nessun dato relativa all\u2019analisi effettuata ai soggetti prima menzionati,<br \/>\ndeve essere espressamente menzionata prima dell\u2019accettazione.<br \/>\nI dati non saranno diffusi in alcun modo. La informiamo inoltre che qualora i Suoi dati dovessero necessitare, per finalit\u00e0 di ricerca scientifica o di<br \/>\nstatistica, saranno trasmessi in modo anonimo.<br \/>\nComunicazione di dati all\u2019interessato:<br \/>\nAi sensi dell\u2019Art 84 comma 1, i dati personali idonei a rilevare il Suo stato di salute saranno resi noti a Lei o ai soggetti di cui all\u2019Art. 82, comma 2,<br \/>\na), dal medico erogante la prestazione o da un altro professionista sanitario. Le ricordiamo che in base all\u2019articolo 7 del Decreto Legislativo<br \/>\n196\/2003 Lei gode di una serie di diritti; per la specifica La invitiamo a richiedere ai nostri operatori copia del testo integrale del decreto. La<br \/>\nmancata richiesta \u00e8 da noi considerata come una preventiva conoscenza dei suoi diritti.<br \/>\nDati relativi al titolare e al responsabile:<br \/>\nTitolare dei trattamenti ai sensi della Legge \u00e8 Medelit s.r.l., con sede in Milano, Via Grado 5.<br \/>\nAi sensi della Legge sono stati nominati i seguenti responsabili interni del trattamento: Direttore Sanitario, Responsabile del trattamento dei dati personali sanitari di competenza, dei dati personali attinenti la gestione amministrativa-contabile e dei dati personali attinenti la gestione giuridico-<br \/>\neconomico-amministrativa del personale.<br \/>\nLa presente informativa e relativo consenso sono da considerarsi validi per il trattamento dei dati personali anche per le eventuali prestazioni che dovessero essere effettuate in futuro, fatta salva ogni disdetta.<\/div><\/div><\/fieldset><div id=\"field_14_90\" class=\"gfield gfield--type-uid gfield--input-type-uid field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"a515b41a\" data-field-span=\"12\"><label id='gfield_label_14_90' class='gfield_label gform-field-label' for='input_14_90'><span class='gform-field-label__text'>Booking ID<\/span><\/label><div class='ginput_container ginput_container_hidden'><input name='input_90' id='input_14_90' type='hidden' value=''  \/><\/div><\/div><div id=\"field_14_123\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"da109967\" data-field-span=\"12\"><label id='gfield_label_14_123' class='gfield_label gform-field-label' for='input_14_123'><span class='gform-field-label__text'>Blacklisted<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_123' id='input_14_123' type='text' value='' class='large'      aria-invalid=\"false\"   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