{"id":55,"date":"2010-08-27T09:30:34","date_gmt":"2010-08-27T09:30:34","guid":{"rendered":"http:\/\/www.medelit.com\/en\/"},"modified":"2026-09-24T09:39:06","modified_gmt":"2026-09-24T07:39:06","slug":"request-house-call","status":"publish","type":"page","link":"https:\/\/www.medelit.com\/it-en\/request-house-call\/","title":{"rendered":"Book a Home or Online Visit"},"content":{"rendered":"<div class=\"mdl-fullwidth fullwidth-box mdl-builder-row-1 mdl-parallax-none nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--mdlb-background-position: left top; --mdlb-padding-top: 120px; --mdlb-padding-bottom: 120px; --mdlb-background-size: cover; --mdlb-flex-wrap: wrap; background-image: url(&quot;https:\/\/www.medelit.com\/it-en\/wp-content\/uploads\/sites\/4\/2016\/04\/shutterstock_338350583.webp&quot;);\" data-bg=\"https:\/\/www.medelit.com\/it-en\/wp-content\/uploads\/sites\/4\/2016\/04\/shutterstock_338350583.webp\">\n<div class=\"mdl-row\">\n<div class=\"mdl-layout-column mdl_builder_column mdl_builder_column_1_1\">\n<div class=\"mdl-column-wrapper\">\n<h1 style=\"text-align: center;\"><span style=\"font-size: 36pt; font-family: georgia, palatino, serif;\">BOOK A HOME VISIT or VIDEO CONSULTATION<\/span><\/h1>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<p style=\"text-align: justify;\"><span style=\"\">The visit, be it a home visit or a video consultation will be delivered according to your requests, at your <strong>home, hotel room, office or any other adequate location you consider comfortable<\/strong>.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"\">We offer home visits in many major cities in Italy but many of our healthcare professionals are also available to carry out video consultations if you are out of their covered areas.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"\">Many of our professionals are available to visit also in areas that we do not usually cover (including other Italian cities and even foreign countries). This will normally imply an extra cost to cover time and travel expenses. Please do not hesitate to contact us for any out-of-area request. We will do all we can to assist you wherever you need us.<\/span><\/p>\n<p><span style=\"\">Booking an appointment with a MEDELIT Healthcare Professional is very easy.<\/span><\/p>\n<p><span style=\"\">Request a House Call or Video Consultation directly:<\/span><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 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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_21' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_21' id='gform_21'  action='\/it-en\/wp-json\/wp\/v2\/pages\/55#gf_21' data-formid='21' novalidate><input type=\"hidden\" name=\"gpuid_existing_value_24\" id=\"gpuid_existing_value_24\" value=\"7e3e2dc7086e13f14d146a36118ef35a\" \/><input type=\"hidden\" name=\"gpuid_existing_value_50\" id=\"gpuid_existing_value_50\" value=\"7e3e2dc7086e13f14d146a36118ef35a\" \/>\n                        <div class='gform-body gform_body'><div id='gform_page_21_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_21' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><div id=\"field_21_198\" 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_21_198' class='gfield_label gform-field-label' for='input_21_198'><span class='gform-field-label__text'>Company<\/span><\/label><div class='ginput_container'><input name='input_198' id='input_21_198' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_21_198'>This field is for validation purposes and should be left unchanged.<\/div><\/div><fieldset id=\"field_21_25\" 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=\"3feb2f7e\" data-field-span=\"12\"><legend id='gfield_label_21_25' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>What would you like to book?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_21_25'>\n\t\t\t<div class='gchoice gchoice_21_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='A DOMICILIO'  id='choice_21_25_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_21_25_0 gfield_label_21_25\"   \/>\n\t\t\t\t\t<label for='choice_21_25_0' id='label_21_25_0' class='gform-field-label gform-field-label--type-inline'>HOME VISIT<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_21_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='In VIDEOCONSULENZA'  id='choice_21_25_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_21_25_1' id='label_21_25_1' class='gform-field-label gform-field-label--type-inline'>VIDEO CONSULTATION<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_21_60\" 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=\"4f4841a7\" data-field-span=\"12\"><label id='gfield_label_21_60' class='gfield_label gform-field-label' for='input_21_60'><span class='gform-field-label__text'>incomingurl<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_21_60' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_28\" 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=\"94165bc9\" data-field-span=\"12\"><label id='gfield_label_21_28' class='gfield_label gform-field-label' for='input_21_28'><span class='gform-field-label__text'>actualurl<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_21_28' type='text' value='https:\/\/www.medelit.com\/it-en\/wp-json\/wp\/v2\/pages\/55' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_61\" 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=\"e2beb877\" data-field-span=\"12\"><label id='gfield_label_21_61' class='gfield_label gform-field-label' for='input_21_61'><span class='gform-field-label__text'>full url<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_21_61' type='text' value='https:\/\/www.medelit.com\/it-en\/wp-json\/wp\/v2\/pages\/55' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_43\" 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=\"f4c51e3d\" data-field-span=\"12\"><label id='gfield_label_21_43' class='gfield_label gform-field-label' for='input_21_43'><span class='gform-field-label__text'>Returning PT ID<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_21_43' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_58\" 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=\"cf94c778\" data-field-span=\"12\"><label id='gfield_label_21_58' class='gfield_label gform-field-label' for='input_21_58'><span class='gform-field-label__text'>SERV TYPE<\/span><\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_58' id='input_21_58' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_62\" 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=\"895e6e4e\" data-field-span=\"12\"><label id='gfield_label_21_62' class='gfield_label gform-field-label' for='input_21_62'><span class='gform-field-label__text'>FIELD<\/span><\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_62' id='input_21_62' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_63\" 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=\"1c6c9d02\" data-field-span=\"12\"><label id='gfield_label_21_63' class='gfield_label gform-field-label' for='input_21_63'><span class='gform-field-label__text'>SUBFIELD<\/span><\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_63' id='input_21_63' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_54\" 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=\"542e307f\" data-field-span=\"12\"><label id='gfield_label_21_54' class='gfield_label gform-field-label' for='input_21_54'><span class='gform-field-label__text'>NEW\/RETURNING PT @new_returning<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_21_54' type='text' value='Di Ritorno' 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_next_button_21_196' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_2' class='gform_page' data-js='page-field-id-196' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_21_2' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><div id=\"field_21_193\" class=\"gfield gfield--type-html medelit-gw-search-mount gfield_html gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"><div id=\"medelit-gw-search\" data-medelit-gw=\"search\"><\/div><\/div><div id=\"field_21_191\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"><label id='gfield_label_21_191' class='gfield_label gform-field-label' for='input_21_191'><span class='gform-field-label__text'>GW SELECTED SERVCODE<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_191' id='input_21_191' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_192\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"><label id='gfield_label_21_192' class='gfield_label gform-field-label' for='input_21_192'><span class='gform-field-label__text'>GW SELECTED SERVICE NAME<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_192' id='input_21_192' 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_21_197' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_21_197' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_3' class='gform_page' data-js='page-field-id-197' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_21_3' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><fieldset id=\"field_21_19\" 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=\"454e73e4\" data-field-span=\"12\"><legend id='gfield_label_21_19' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you a new or a returning patient?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_21_19'>\n\t\t\t<div class='gchoice gchoice_21_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Nuovo'  id='choice_21_19_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_21_19_0 gfield_label_21_19\"   \/>\n\t\t\t\t\t<label for='choice_21_19_0' id='label_21_19_0' class='gform-field-label gform-field-label--type-inline'>New patient<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_21_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Di Ritorno'  id='choice_21_19_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_21_19_1' id='label_21_19_1' class='gform-field-label gform-field-label--type-inline'>Returning patient<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_21_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"f9cc38f8\" data-field-span=\"12\"><label id='gfield_label_21_42' class='gfield_label gform-field-label' for='input_21_42'><span class='gform-field-label__text'>CODICE FISCALE (Italian tax code)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_21_42' type='text' value='' class='large'  aria-describedby=\"gfield_description_21_42\"  placeholder='aaaaaa99a99a999a' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"aaaaaa99a99a999a\"\/><\/div><div class='gfield_description' id='gfield_description_21_42'>Or tick the box below if you do not have an Italian tax code.<\/div><\/div><fieldset id=\"field_21_194\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_21_194' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>I do not have an Italian tax code (Codice Fiscale)<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_21_194'><div class='gchoice gchoice_21_194_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.1' type='checkbox'  value='Y'  id='choice_21_194_1'    aria-labelledby=\"label_21_194_1 gfield_label_21_194\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_21_194_1' id='label_21_194_1' class='gform-field-label gform-field-label--type-inline'>I do not have an Italian tax code (Codice Fiscale) \u2014 find me by email<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_21_195\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"><label id='gfield_label_21_195' class='gfield_label gform-field-label' for='input_21_195'><span class='gform-field-label__text'>EMAIL ADDRESS used for your previous bookings<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_195' id='input_21_195' type='email' value='' class='large'   placeholder='name@example.com' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_21_195\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_21_195'>We will look you up by this email address. If we cannot find you, please choose \"New patient\".<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_21_69' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_21_69' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_4' class='gform_page' data-js='page-field-id-69' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_21_4' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><div id=\"field_21_56\" 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=\"773616a0\" data-field-span=\"12\"><p style=\"text-align: justify; font-size: 18px; color: #CA1517;\">\n    No patient found on our system - Please check that you have entered your CODICE FISCALE (or the email address used for your previous bookings) correctly and selected the right option under New \/ Returning patient\n<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_21_68' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_21_68' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_5' class='gform_page' data-js='page-field-id-68' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_21_5' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><fieldset id=\"field_21_45\" 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=\"60ac0634\" data-field-span=\"12\"><legend id='gfield_label_21_45' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Is the visit address the same as last time?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_21_45'>\n\t\t\t<div class='gchoice gchoice_21_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='SI'  id='choice_21_45_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_21_45_0 gfield_label_21_45\"   \/>\n\t\t\t\t\t<label for='choice_21_45_0' id='label_21_45_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_21_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='NO \/ NON SONO SICURO\/A'  id='choice_21_45_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_21_45_1' id='label_21_45_1' class='gform-field-label gform-field-label--type-inline'>NO \/ NOT SURE<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_21_48\" 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=\"1160782f\" data-field-span=\"12\"><legend id='gfield_label_21_48' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>RETURNING PT SYSTEM VISIT ADDRESS<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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_21_48' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_21_48_1_container' >\n                                        <input type='text' name='input_48.1' id='input_21_48_1' value=''    aria-required='true'    aria-labelledby=\"input_21_48_1_label gfield_label_21_48\"\/>\n                                        <label for='input_21_48_1' id='input_21_48_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_21_48_3_container' >\n                                    <input type='text' name='input_48.3' id='input_21_48_3' value=''    aria-required='true'    \/>\n                                    <label for='input_21_48_3' id='input_21_48_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_21_48_4_container' >\n                                        <input type='text' name='input_48.4' id='input_21_48_4' value=''      aria-required='true'    \/>\n                                        <label for='input_21_48_4' id='input_21_48_4_label' class='gform-field-label gform-field-label--type-sub '>County \/ State \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_21_48_5_container' >\n                                    <input type='text' name='input_48.5' id='input_21_48_5' value=''    aria-required='true'    \/>\n                                    <label for='input_21_48_5' id='input_21_48_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_21_48_6_container' >\n                                        <select name='input_48.6' id='input_21_48_6'   aria-required='true'    ><option value='' ><\/option><option value='AF' >Afghanistan<\/option><option value='AX' >\u00c5land Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/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='BY' >Belarus<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/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' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='CV' >Cape Verde<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Democratic Republic of the<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='CI' >C\u00f4te d&#039;Ivoire<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czechia<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >Eswatini<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='VA' >Holy See<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='KP' >Korea, Democratic People&#039;s Republic of<\/option><option value='KR' >Korea, Republic of<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Lao People&#039;s Democratic Republic<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='MK' >North Macedonia<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PS' >Palestine, State of<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='RE' >R\u00e9union<\/option><option value='RO' >Romania<\/option><option value='RU' >Russian Federation<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='SH' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='MF' >Saint Martin<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/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' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia and the South Sandwich Islands<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria Arab Republic<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania, the United Republic of<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >T\u00fcrkiye<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom<\/option><option value='US' >United States<\/option><option value='UY' >Uruguay<\/option><option value='UM' >US Minor Outlying Islands<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Viet Nam<\/option><option value='VG' >Virgin Islands, British<\/option><option value='VI' >Virgin Islands, U.S.<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select>\n                                        <label for='input_21_48_6' id='input_21_48_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_21_55' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_21_55' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_6' class='gform_page' data-js='page-field-id-55' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_21_6' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><fieldset id=\"field_21_15\" 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=\"fb03d56d\" data-field-span=\"12\"><legend id='gfield_label_21_15' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>VISIT ADDRESS<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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_21_15' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_21_15_1_container' >\n                                        <input type='text' name='input_15.1' id='input_21_15_1' value=''   placeholder='Type the visit address here' aria-required='true'    aria-labelledby=\"input_21_15_1_label gfield_label_21_15\"\/>\n                                        <label for='input_21_15_1' id='input_21_15_1_label' class='gform-field-label gform-field-label--type-sub '>Street\/Square\/Avenue and HOUSE NUMBER<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_21_15_3_container' >\n                                    <input type='text' name='input_15.3' id='input_21_15_3' value=''    aria-required='true'    \/>\n                                    <label for='input_21_15_3' id='input_21_15_3_label' class='gform-field-label gform-field-label--type-sub '>Visit town<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_21_15_4_container' >\n                                        <input type='text' name='input_15.4' id='input_21_15_4' value=''      aria-required='true'    \/>\n                                        <label for='input_21_15_4' id='input_21_15_4_label' class='gform-field-label gform-field-label--type-sub '>Visit province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_21_15_5_container' >\n                                    <input type='text' name='input_15.5' id='input_21_15_5' value=''    aria-required='true'    \/>\n                                    <label for='input_21_15_5' id='input_21_15_5_label' class='gform-field-label gform-field-label--type-sub '>Visit postcode<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_21_15_6_container' >\n                                        <select name='input_15.6' id='input_21_15_6'   aria-required='true'    ><option value='' ><\/option><option value='AF' >Afghanistan<\/option><option value='AX' >\u00c5land Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/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='BY' >Belarus<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/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' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='CV' >Cape Verde<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Democratic Republic of the<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='CI' >C\u00f4te d&#039;Ivoire<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czechia<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >Eswatini<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='VA' >Holy See<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' selected='selected'>Italy<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='KP' >Korea, Democratic People&#039;s Republic of<\/option><option value='KR' >Korea, Republic of<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Lao People&#039;s Democratic Republic<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='MK' >North Macedonia<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PS' >Palestine, State of<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='RE' >R\u00e9union<\/option><option value='RO' >Romania<\/option><option value='RU' >Russian Federation<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='SH' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='MF' >Saint Martin<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/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' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia and the South Sandwich Islands<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria Arab Republic<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania, the United Republic of<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >T\u00fcrkiye<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom<\/option><option value='US' >United States<\/option><option value='UY' >Uruguay<\/option><option value='UM' >US Minor Outlying Islands<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Viet Nam<\/option><option value='VG' >Virgin Islands, British<\/option><option value='VI' >Virgin Islands, U.S.<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select>\n                                        <label for='input_21_15_6' id='input_21_15_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><input type=\"hidden\" name=\"gpaa_place_15\" class=\"gform_hidden\" value=\"\"><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_21_81' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_21_81' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_7' class='gform_page' data-js='page-field-id-81' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_21_7' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><fieldset id=\"field_21_47\" 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=\"1454a830\" data-field-span=\"12\"><legend id='gfield_label_21_47' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>CURRENT VISIT ADDRESS<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip has_country ginput_container_address gform-grid-row' id='input_21_47' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_21_47_1_container' >\n                                        <input type='text' name='input_47.1' id='input_21_47_1' value=''    aria-required='true'    aria-labelledby=\"input_21_47_1_label gfield_label_21_47\"\/>\n                                        <label for='input_21_47_1' id='input_21_47_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_21_47_3_container' >\n                                    <input type='text' name='input_47.3' id='input_21_47_3' value=''    aria-required='true'    \/>\n                                    <label for='input_21_47_3' id='input_21_47_3_label' class='gform-field-label gform-field-label--type-sub '>Town\/City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_47.4' id='input_21_47_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_21_47_5_container' >\n                                    <input type='text' name='input_47.5' id='input_21_47_5' value=''    aria-required='true'    \/>\n                                    <label for='input_21_47_5' id='input_21_47_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_21_47_6_container' >\n                                        <select name='input_47.6' id='input_21_47_6'   aria-required='true'    ><option value='' ><\/option><option value='AF' >Afghanistan<\/option><option value='AX' >\u00c5land Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/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='BY' >Belarus<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/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' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='CV' >Cape Verde<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Democratic Republic of the<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='CI' >C\u00f4te d&#039;Ivoire<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czechia<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >Eswatini<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='VA' >Holy See<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' selected='selected'>Italy<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='KP' >Korea, Democratic People&#039;s Republic of<\/option><option value='KR' >Korea, Republic of<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Lao People&#039;s Democratic Republic<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='MK' >North Macedonia<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PS' >Palestine, State of<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='RE' >R\u00e9union<\/option><option value='RO' >Romania<\/option><option value='RU' >Russian Federation<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='SH' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='MF' >Saint Martin<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/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' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia and the South Sandwich Islands<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria Arab Republic<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania, the United Republic of<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >T\u00fcrkiye<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom<\/option><option value='US' >United States<\/option><option value='UY' >Uruguay<\/option><option value='UM' >US Minor Outlying Islands<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Viet Nam<\/option><option value='VG' >Virgin Islands, British<\/option><option value='VI' >Virgin Islands, U.S.<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select>\n                                        <label for='input_21_47_6' id='input_21_47_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><input type=\"hidden\" name=\"gpaa_place_47\" class=\"gform_hidden\" value=\"\"><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_21_79' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Go back<\/button> <button type='button' id='gform_next_button_21_79' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_21_8' class='gform_page' data-js='page-field-id-79' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_21_8' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><div id=\"field_21_59\" 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=\"eb64c49c\" data-field-span=\"12\"><label id='gfield_label_21_59' class='gfield_label gform-field-label' for='input_21_59'><span class='gform-field-label__text'>Video placeholder address<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_21_59' type='text' value='XXXXVID' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_37\" 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=\"9362f0fa\" data-field-span=\"12\"><label id='gfield_label_21_37' class='gfield_label gform-field-label' for='input_21_37'><span class='gform-field-label__text'>servcode<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_21_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_80\" 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=\"8c577d9e\" data-field-span=\"12\"><label id='gfield_label_21_80' class='gfield_label gform-field-label' for='input_21_80'><span class='gform-field-label__text'>YOU HAVE SELECTED THE SERVICE:<\/span><\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_80' id='input_21_80' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_24\" class=\"gfield gfield--type-uid gfield--input-type-uid gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"12d4f624\" data-field-span=\"12\"><label id='gfield_label_21_24' class='gfield_label gform-field-label' for='input_21_24'><span class='gform-field-label__text'>cnn<\/span><\/label><div class='ginput_container ginput_container_hidden'><input name='input_24' id='input_21_24' type='hidden' value=''  \/><\/div><\/div><div id=\"field_21_50\" class=\"gfield gfield--type-uid gfield--input-type-uid gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"771dddea\" data-field-span=\"12\"><label id='gfield_label_21_50' class='gfield_label gform-field-label' for='input_21_50'><span class='gform-field-label__text'>PATIENT ID<\/span><\/label><div class='ginput_container ginput_container_hidden'><input name='input_50' id='input_21_50' type='hidden' value=''  \/><\/div><\/div><div id=\"field_21_40\" 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=\"f9a27dee\" data-field-span=\"12\"><label id='gfield_label_21_40' class='gfield_label gform-field-label' for='input_21_40'><span class='gform-field-label__text'>CONNECTED SERVICES servocde<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_21_40' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_38\" 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=\"2cb207b8\" data-field-span=\"12\"><label id='gfield_label_21_38' class='gfield_label gform-field-label' for='input_21_38'><span class='gform-field-label__text'>CONNECTED VIDEO servcode<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_21_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_32\" 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=\"bf1065ea\" data-field-span=\"12\"><label id='gfield_label_21_32' class='gfield_label 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s=document.createElement(\"script\");s.src=\"https:\/\/challenges.cloudflare.com\/turnstile\/v0\/api.js?render=explicit\";s.async=true;s.defer=true;s.onload=function(){window.medelitTsRender()};document.head.appendChild(s)};var E=[\"pointerdown\",\"touchstart\",\"keydown\",\"mousemove\",\"wheel\"],H=function(){E.forEach(function(e){removeEventListener(e,H,true)});L()};E.forEach(function(e){addEventListener(e,H,{capture:true,passive:true})});}<\/script><\/p>\n<h2 style=\"text-align: center;\"><span style=\"font-size: 36pt; font-family: georgia, palatino, serif;\">TERMS AND CONDITIONS<\/span><\/h2>\n<div class=\"accordian mdl-accordian\" style=\"--mdlb-border-size:1px;--mdlb-icon-size:13px;--mdlb-content-font-size:16px;--mdlb-icon-alignment:left;--mdlb-hover-color:#f9f9f9;--mdlb-border-color:#cccccc;--mdlb-background-color:#ffffff;--mdlb-divider-color:#e0dede;--mdlb-divider-hover-color:#e0dede;--mdlb-icon-color:#ffffff;--mdlb-title-color:#ca1517;--mdlb-content-color:#000000;--mdlb-icon-box-color:#333333;--mdlb-toggle-hover-accent-color:#ca1517;--mdlb-title-font-family:&quot;Raleway&quot;;--mdlb-title-font-weight:400;--mdlb-title-font-style:normal;--mdlb-title-font-size:13px;--mdlb-content-font-family:&quot;Raleway&quot;;--mdlb-content-font-style:normal;--mdlb-content-font-weight:200;\">\n<div class=\"panel-group mdl-toggle-icon-boxed\" id=\"accordion-55-1\">\n<div class=\"mdl-panel panel-default panel-a42f88afa1b2c3d4 mdl-toggle-has-divider\">\n<div class=\"panel-heading\">\n<h4 class=\"panel-title toggle\" id=\"toggle_a42f88afa1b2c3d4\"><a aria-expanded=\"false\" aria-controls=\"a42f88afa1b2c3d4\" role=\"button\" data-toggle=\"collapse\" data-parent=\"#accordion-55-1\" data-target=\"#a42f88afa1b2c3d4\" href=\"#a42f88afa1b2c3d4\"><span class=\"mdl-toggle-icon-wrapper\" aria-hidden=\"true\"><i class=\"fa-mdl-box active-icon mdlb-icon-minus\" aria-hidden=\"true\"><\/i><i class=\"fa-mdl-box inactive-icon mdlb-icon-plus\" aria-hidden=\"true\"><\/i><\/span><span class=\"mdl-toggle-heading\">PAYMENT METHODS<\/span><\/a><\/h4>\n<\/div>\n<div id=\"a42f88afa1b2c3d4\" class=\"panel-collapse collapse\" aria-labelledby=\"toggle_a42f88afa1b2c3d4\">\n<div class=\"panel-body toggle-content mdl-clearfix\">Payment can be made by:<\/p>\n<ul>\n<li style=\"text-align: justify;\">CREDIT CARD:<br \/> At the moment of booking confirmation. Your card is charged only once the service has taken place.<\/li>\n<\/ul>\n<ul>\n<li style=\"text-align: justify;\">BANK TRANSFER:<br \/> Your booking is confirmed only on receipt of a copy of the transfer slip, which must reach us within the deadline stated in the booking-option email. Any communication or payment received after that deadline does not oblige Medelit to hold the appointment originally proposed, and the request is automatically redirected to a new slot in the professional&rsquo;s diary.<\/li>\n<\/ul>\n<p>Bank account details:<\/p>\n<p>MEDELIT SRL<br \/> Banca Fideuram<br \/> SWIFT: FIBKITMM<br \/> Iban: IT77 P032 9601 6010 0006 4346 868<\/p>\n<p style=\"text-align: justify;\">Your invoice is sent by email to the address given at the time of booking.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mdl-panel panel-default panel-a42f88b0a1b2c3d4 mdl-toggle-has-divider\">\n<div class=\"panel-heading\">\n<h4 class=\"panel-title toggle\" id=\"toggle_a42f88b0a1b2c3d4\"><a aria-expanded=\"false\" aria-controls=\"a42f88b0a1b2c3d4\" role=\"button\" data-toggle=\"collapse\" data-parent=\"#accordion-55-1\" data-target=\"#a42f88b0a1b2c3d4\" href=\"#a42f88b0a1b2c3d4\"><span class=\"mdl-toggle-icon-wrapper\" aria-hidden=\"true\"><i class=\"fa-mdl-box active-icon mdlb-icon-minus\" aria-hidden=\"true\"><\/i><i class=\"fa-mdl-box inactive-icon mdlb-icon-plus\" aria-hidden=\"true\"><\/i><\/span><span class=\"mdl-toggle-heading\">PRICES AND DISCOUNTS<\/span><\/a><\/h4>\n<\/div>\n<div id=\"a42f88b0a1b2c3d4\" class=\"panel-collapse collapse\" aria-labelledby=\"toggle_a42f88b0a1b2c3d4\">\n<div class=\"panel-body toggle-content mdl-clearfix\">\n<p style=\"text-align: justify;\">The costs for a house call are not significantly higher than those requested on average for a consultation in a private clinic or doctor\u2019s office.<\/p>\n<p style=\"text-align: justify;\">The fee is adjusted only so as to ensure coverage for the healthcare professional\u2019s transfer and is equivalent to the costs of taking a cab in the city.<\/p>\n<p style=\"text-align: justify;\">Medelit also provides many packages&nbsp;and discounted services.<\/p>\n<p style=\"text-align: justify;\">Call us or send us an email to request further information. We will supply you with information on the best solution available according to your needs.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mdl-panel panel-default panel-a42f88b1a1b2c3d4 mdl-toggle-has-divider\">\n<div class=\"panel-heading\">\n<h4 class=\"panel-title toggle\" id=\"toggle_a42f88b1a1b2c3d4\"><a aria-expanded=\"false\" aria-controls=\"a42f88b1a1b2c3d4\" role=\"button\" data-toggle=\"collapse\" data-parent=\"#accordion-55-1\" data-target=\"#a42f88b1a1b2c3d4\" href=\"#a42f88b1a1b2c3d4\"><span class=\"mdl-toggle-icon-wrapper\" aria-hidden=\"true\"><i class=\"fa-mdl-box active-icon mdlb-icon-minus\" aria-hidden=\"true\"><\/i><i class=\"fa-mdl-box inactive-icon mdlb-icon-plus\" aria-hidden=\"true\"><\/i><\/span><span class=\"mdl-toggle-heading\">CANCELLATION POLICY<\/span><\/a><\/h4>\n<\/div>\n<div id=\"a42f88b1a1b2c3d4\" class=\"panel-collapse collapse\" aria-labelledby=\"toggle_a42f88b1a1b2c3d4\">\n<div class=\"panel-body toggle-content mdl-clearfix\">\n<p style=\"text-align: justify;\">Organising a home visit or an online consultation involves a considerable commitment, both organisationally and in the time the professional sets aside for you. We therefore ask every patient to let us know in good time of any change or cancellation, whether the appointment is at home or online, so that the slot can be offered to someone else who needs our help. Cancellations and rescheduling requests are subject to the same conditions.<\/p>\n<p style=\"text-align: justify;\">Cancellations, rescheduling requests and missed appointments may incur a charge. The full cancellation policy, including any fees, is sent to you in writing with your booking option before you pay, and you confirm your acceptance at payment.<\/p>\n<p style=\"text-align: justify;\">How to communicate a change or cancellation is explained in your booking email. Medelit cannot process or reply to cancellations or changes sent through any other channel, which are void.<\/p>\n<p style=\"text-align: justify;\">Any communication or payment received after the deadline stated in the booking option does not oblige Medelit to hold the appointment originally proposed; the request is redirected to a new slot in the professional&rsquo;s diary. Any cancellation after a transfer slip has been sent, or a payment made after the deadline, is handled under our cancellation policy.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mdl-panel panel-default panel-a42f88b2a1b2c3d4 mdl-toggle-has-divider\">\n<div class=\"panel-heading\">\n<h4 class=\"panel-title toggle\" id=\"toggle_a42f88b2a1b2c3d4\"><a aria-expanded=\"false\" aria-controls=\"a42f88b2a1b2c3d4\" role=\"button\" data-toggle=\"collapse\" data-parent=\"#accordion-55-1\" data-target=\"#a42f88b2a1b2c3d4\" href=\"#a42f88b2a1b2c3d4\"><span class=\"mdl-toggle-icon-wrapper\" aria-hidden=\"true\"><i class=\"fa-mdl-box active-icon mdlb-icon-minus\" aria-hidden=\"true\"><\/i><i class=\"fa-mdl-box inactive-icon mdlb-icon-plus\" aria-hidden=\"true\"><\/i><\/span><span class=\"mdl-toggle-heading\">SERVICE PROVISION CONDITIONS<\/span><\/a><\/h4>\n<\/div>\n<div id=\"a42f88b2a1b2c3d4\" class=\"panel-collapse collapse\" aria-labelledby=\"toggle_a42f88b2a1b2c3d4\">\n<div class=\"panel-body toggle-content mdl-clearfix\">\n<p>Anyone can have an emergency, and that includes our healthcare professionals.<\/p>\n<p style=\"text-align: justify;\">In case of an emergency, a professional may need to move or cancel a confirmed appointment. Medelit is a home healthcare service, not an emergency or out-of-hours service, nor a hospital with staff available 24 hours a day.<\/p>\n<p style=\"text-align: justify;\">If an appointment is moved or cancelled because of the professional&rsquo;s emergency, we immediately look for a replacement; we cannot, however, guarantee that it will be on the same day or at the same time as the appointment previously confirmed.<\/p>\n<p style=\"text-align: justify;\">If we are unable to find new availability with our professionals, or the new proposals are not consistent with what is clinically indicated, the service is refunded in full.<\/p>\n<p style=\"text-align: justify;\">If every alternative appointment proposal is refused, the booking is treated as cancelled and handled under our cancellation policy.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mdl-panel panel-default panel-a42f88b3a1b2c3d4 mdl-toggle-has-divider\">\n<div class=\"panel-heading\">\n<h4 class=\"panel-title toggle\" id=\"toggle_a42f88b3a1b2c3d4\"><a aria-expanded=\"false\" aria-controls=\"a42f88b3a1b2c3d4\" role=\"button\" data-toggle=\"collapse\" data-parent=\"#accordion-55-1\" data-target=\"#a42f88b3a1b2c3d4\" href=\"#a42f88b3a1b2c3d4\"><span class=\"mdl-toggle-icon-wrapper\" aria-hidden=\"true\"><i class=\"fa-mdl-box active-icon mdlb-icon-minus\" aria-hidden=\"true\"><\/i><i class=\"fa-mdl-box inactive-icon mdlb-icon-plus\" aria-hidden=\"true\"><\/i><\/span><span class=\"mdl-toggle-heading\">HOW TO COMMUNICATE APPOINTMENT CHANGES<\/span><\/a><\/h4>\n<\/div>\n<div id=\"a42f88b3a1b2c3d4\" class=\"panel-collapse collapse\" aria-labelledby=\"toggle_a42f88b3a1b2c3d4\">\n<div class=\"panel-body toggle-content mdl-clearfix\">\n<p style=\"text-align: justify;\">When your booking is confirmed we send you the access link to your patient portal, through which you can tell your professional directly if you need to change or cancel a confirmed appointment. It is a single point of contact, available at any time, and your professional is informed immediately.<\/p>\n<p style=\"text-align: justify;\">If you ask to change the time of an appointment, your professional will do their best to accommodate you; changes requested with less than 24 hours&rsquo; notice cannot be guaranteed, and if you are then unable to keep the original time our cancellation policy applies.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>BOOK A HOME VISIT or VIDEO CONSULTATION The visit, be it a home visit or a video consultation will be [&hellip;]<\/p>\n","protected":false},"author":10,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"open","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-55","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.8 - 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