{"id":55,"date":"2010-08-27T09:30:34","date_gmt":"2010-08-27T09:30:34","guid":{"rendered":"http:\/\/www.medelit.com\/en\/"},"modified":"2026-06-16T16:12:11","modified_gmt":"2026-06-16T14:12:11","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 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 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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_4' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Book A Home Visit<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/it-en\/wp-json\/wp\/v2\/pages\/55#gf_4' data-formid='4' novalidate><input type=\"hidden\" name=\"gpuid_existing_value_71\" id=\"gpuid_existing_value_71\" value=\"7e3e2dc7086e13f14d146a36118ef35a\" \/><input type=\"hidden\" name=\"gpuid_existing_value_73\" id=\"gpuid_existing_value_73\" value=\"7e3e2dc7086e13f14d146a36118ef35a\" \/><input type=\"hidden\" name=\"gpuid_existing_value_72\" id=\"gpuid_existing_value_72\" value=\"7e3e2dc7086e13f14d146a36118ef35a\" \/>\n        <div id='gf_progressbar_wrapper_4' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>7<\/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_14' style='width:14%;'><span>14%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_4_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_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_102\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_102'><span class='gform-field-label__text'>Company<\/span><\/label><div class='ginput_container'><input name='input_102' id='input_4_102' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_4_102'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_4_71\" 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\"  ><label class='gfield_label gform-field-label' for='input_4_71'><span class='gform-field-label__text'>cn<\/span><\/label><div class='ginput_container ginput_container_hidden'><input name='input_71' id='input_4_71' type='hidden' value=''  \/><\/div><\/div><div id=\"field_4_73\" 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\"  ><label class='gfield_label gform-field-label' for='input_4_73'><span class='gform-field-label__text'>BOOKING ID<\/span><\/label><div class='ginput_container ginput_container_hidden'><input name='input_73' id='input_4_73' type='hidden' value=''  \/><\/div><\/div><div id=\"field_4_34\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"form-title\">Some fields are mandatory so as to assist you and invoice the service we will provide (*) <\/h3><\/div><fieldset id=\"field_4_47\" 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\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>I have already received confirmation of service cover and fees at my address by Medelit&#039;s Operations Team, and now want to proceed with a BOOKING.<\/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_4_47'>\n\t\t\t<div class='gchoice gchoice_4_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Yes'  id='choice_4_47_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_4_47\"   \/>\n\t\t\t\t\t<label for='choice_4_47_0' id='label_4_47_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_4_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='No'  id='choice_4_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_47_1' id='label_4_47_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_4_47'>PLEASE TAKE NOTICE - \nThis is not an enquiry form. Please do NOT use this form prior to contacting us for confirmation of cover and fees at your address. \n\nWE only provide home healthcare services in ITALY.<\/div><\/fieldset><div id=\"field_4_50\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"form-title\">This is a booking form. Please contact us by chat, phone or through our   <a href=\"https:\/\/www.medelit.com\/uk\/contact-us\/\">info request form<\/a> to receive information regarding cover of service and fees for your area <\/h3><\/div><fieldset id=\"field_4_45\" 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\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>I am<\/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_4_45'>\n\t\t\t<div class='gchoice gchoice_4_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='A New patient'  id='choice_4_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_45_0' id='label_4_45_0' class='gform-field-label gform-field-label--type-inline'>A New patient<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='A returning patient'  id='choice_4_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_45_1' id='label_4_45_1' class='gform-field-label gform-field-label--type-inline'>A returning patient<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_62\" 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\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>I AM BOOKING:<\/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_4_62'>\n\t\t\t<div class='gchoice gchoice_4_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='HOME VISIT'  id='choice_4_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_62_0' id='label_4_62_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_4_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='ONLINE SERVICE'  id='choice_4_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_62_1' id='label_4_62_1' class='gform-field-label gform-field-label--type-inline'>ONLINE SERVICE<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <button type='button' id='gform_next_button_4_67' 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_4_2' class='gform_page' data-js='page-field-id-67' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_4_46\" 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\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>PATIENT Name and Surname<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_4_46'>\n                            \n                            <span id='input_4_46_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_46.3' id='input_4_46_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_46_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_4_46_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_46.4' id='input_4_46_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_46_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_4_46_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_46.6' id='input_4_46_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_46_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_4_4\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_4_4_container'>\n                                <span id='input_4_4_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_4' id='input_4_4' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_4_4' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_4_4_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_4_2' id='input_4_4_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_4_4_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_4_39\" 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\"  ><label class='gfield_label gform-field-label' for='input_4_39'><span class='gform-field-label__text'>Date of Birth<\/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='dd\/mm\/yyyy'\n\t\t\t\t\tid='input_4_39'\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_39'\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_4_39' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_4_39' 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_4_39' aria-label='Date of Birth: 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_4_75\" 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\"  ><label class='gfield_label gform-field-label' for='input_4_75'><span class='gform-field-label__text'>Do You have an italian CODICE FISCALE?<\/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_75' id='input_4_75' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='YES' >YES<\/option><option value='NO' >NO<\/option><\/select><\/div><\/div><div id=\"field_4_76\" 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\"  ><label class='gfield_label gform-field-label' for='input_4_76'><span class='gform-field-label__text'>CODICE FISCALE<\/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_76' id='input_4_76' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_74\" 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\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_74'><span class='gform-field-label__text'>RETURNING PT ID<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_4_74' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_72\" 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\"  ><label class='gfield_label gform-field-label' for='input_4_72'><span class='gform-field-label__text'>PT ID<\/span><\/label><div class='ginput_container ginput_container_hidden'><input name='input_72' id='input_4_72' type='hidden' value=''  \/><\/div><\/div><div id=\"field_4_95\" 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\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_95'><span class='gform-field-label__text'>New\/returning PT<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_4_95' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_43\" 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\"  ><label class='gfield_label gform-field-label' for='input_4_43'><span class='gform-field-label__text'>Country of Birth<\/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_43' id='input_4_43' type='text' value='' class='medium'     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_previous_button_4_77' 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_4_77' 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_4_3' class='gform_page' data-js='page-field-id-77' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_6\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_6'><span class='gform-field-label__text'>Telephone for Contact<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_4_6'>Provide a MOBILE number<\/div><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_4_6' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_4_6\"   \/><\/div><\/div><div id=\"field_4_32\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_32'><span class='gform-field-label__text'>Telephone 2<\/span><\/label><div class='gfield_description' id='gfield_description_4_32'>Please leave us 2 phone numbers if possible<\/div><div class='ginput_container ginput_container_phone'><input name='input_32' id='input_4_32' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_4_32\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_4_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_4_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_4_4' class='gform_page' data-js='page-field-id-68' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_37\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"form-title\">Home visit information <\/h3><\/div><fieldset id=\"field_4_84\" 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_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Visit Address on System<\/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_4_84' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_84_1_container' >\n                                        <input type='text' name='input_84.1' id='input_4_84_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_84_1' id='input_4_84_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_4_84_3_container' >\n                                    <input type='text' name='input_84.3' id='input_4_84_3' value=''    aria-required='false'    \/>\n                                    <label for='input_4_84_3' id='input_4_84_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_4_84_4_container' >\n                                        <input type='text' name='input_84.4' id='input_4_84_4' value=''      aria-required='false'    \/>\n                                        <label for='input_4_84_4' id='input_4_84_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_4_84_5_container' >\n                                    <input type='text' name='input_84.5' id='input_4_84_5' value=''    aria-required='false'    \/>\n                                    <label for='input_4_84_5' id='input_4_84_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_4_84_6_container' >\n                                        <select name='input_84.6' id='input_4_84_6'   aria-required='false'    ><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_4_84_6' id='input_4_84_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 id=\"field_4_80\" 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\"  ><label class='gfield_label gform-field-label' for='input_4_80'><span class='gform-field-label__text'>Is the visit always at the same Address?<\/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_80' id='input_4_80' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='YES' >YES<\/option><option value='NO\/NOT SURE' >NO\/NOT SURE<\/option><\/select><\/div><\/div><div id=\"field_4_92\" 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\"  ><label class='gfield_label gform-field-label' for='input_4_92'><span class='gform-field-label__text'>Is the Invoicing Address always the same?<\/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_92' id='input_4_92' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='YES' >YES<\/option><option value='NO\/NOT SURE' >NO\/NOT SURE<\/option><\/select><\/div><\/div><fieldset id=\"field_4_93\" 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\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Updated 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_4_93' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_93_1_container' >\n                                        <input type='text' name='input_93.1' id='input_4_93_1' value=''    aria-required='true'    \/>\n                                        <label for='input_4_93_1' id='input_4_93_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_4_93_3_container' >\n                                    <input type='text' name='input_93.3' id='input_4_93_3' value=''    aria-required='true'    \/>\n                                    <label for='input_4_93_3' id='input_4_93_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_4_93_4_container' >\n                                        <input type='text' name='input_93.4' id='input_4_93_4' value=''      aria-required='true'    \/>\n                                        <label for='input_4_93_4' id='input_4_93_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_4_93_5_container' >\n                                    <input type='text' name='input_93.5' id='input_4_93_5' value=''    aria-required='true'    \/>\n                                    <label for='input_4_93_5' id='input_4_93_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_4_93_6_container' >\n                                        <select name='input_93.6' id='input_4_93_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_4_93_6' id='input_4_93_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><fieldset id=\"field_4_81\" 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\"  ><legend 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_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_4_81' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_81_1_container' >\n                                        <input type='text' name='input_81.1' id='input_4_81_1' value=''    aria-required='true'    \/>\n                                        <label for='input_4_81_1' id='input_4_81_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_4_81_3_container' >\n                                    <input type='text' name='input_81.3' id='input_4_81_3' value=''    aria-required='true'    \/>\n                                    <label for='input_4_81_3' id='input_4_81_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_4_81_4_container' >\n                                        <input type='text' name='input_81.4' id='input_4_81_4' value=''      aria-required='true'    \/>\n                                        <label for='input_4_81_4' id='input_4_81_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_4_81_5_container' >\n                                    <input type='text' name='input_81.5' id='input_4_81_5' value=''    aria-required='true'    \/>\n                                    <label for='input_4_81_5' id='input_4_81_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_4_81_6_container' >\n                                        <select name='input_81.6' id='input_4_81_6'   aria-required='true'    ><option value='' >Italy<\/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_4_81_6' id='input_4_81_6_label' class='gform-field-label gform-field-label--type-sub '>Italy<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><input type=\"hidden\" name=\"gpaa_place_81\" class=\"gform_hidden\" value=\"\"><\/fieldset><fieldset id=\"field_4_83\" 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\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Updated Visit 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_4_83' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_83_1_container' >\n                                        <input type='text' name='input_83.1' id='input_4_83_1' value=''    aria-required='true'    \/>\n                                        <label for='input_4_83_1' id='input_4_83_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_4_83_3_container' >\n                                    <input type='text' name='input_83.3' id='input_4_83_3' value=''    aria-required='true'    \/>\n                                    <label for='input_4_83_3' id='input_4_83_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_4_83_4_container' >\n                                        <input type='text' name='input_83.4' id='input_4_83_4' value=''      aria-required='true'    \/>\n                                        <label for='input_4_83_4' id='input_4_83_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_4_83_5_container' >\n                                    <input type='text' name='input_83.5' id='input_4_83_5' value=''    aria-required='true'    \/>\n                                    <label for='input_4_83_5' id='input_4_83_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_4_83_6_container' >\n                                        <select name='input_83.6' id='input_4_83_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_4_83_6' id='input_4_83_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_83\" class=\"gform_hidden\" value=\"\"><\/fieldset><div id=\"field_4_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_12'><span class='gform-field-label__text'>Street Level Intercom<\/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_12' id='input_4_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_85\" 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\"  ><label class='gfield_label gform-field-label' for='input_4_85'><span class='gform-field-label__text'>Updated Street Level Intercom<\/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_85' id='input_4_85' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_88\" 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\"  ><label class='gfield_label gform-field-label' for='input_4_88'><span class='gform-field-label__text'>Floor<\/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_88' id='input_4_88' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><\/select><\/div><\/div><div id=\"field_4_89\" 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\"  ><label class='gfield_label gform-field-label' for='input_4_89'><span class='gform-field-label__text'>Updated Floor<\/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_89' id='input_4_89' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><\/select><\/div><\/div><div id=\"field_4_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_13'><span class='gform-field-label__text'>Apt\/Staircase<\/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_13' id='input_4_13' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_86\" 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\"  ><label class='gfield_label gform-field-label' for='input_4_86'><span class='gform-field-label__text'>Updated Apt\/Staircase<\/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_86' id='input_4_86' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_40\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"form-title\">Invoice Information<\/h3><\/div><fieldset id=\"field_4_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Is your invoicing Address the same as your visit Address?<\/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_4_18'>\n\t\t\t<div class='gchoice gchoice_4_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Yes'  id='choice_4_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_18_0' id='label_4_18_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_4_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='No'  id='choice_4_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_18_1' id='label_4_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_90\" 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_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>System Invoicing Address<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_4_90' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_90_1_container' >\n                                        <input type='text' name='input_90.1' id='input_4_90_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_90_1' id='input_4_90_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_4_90_2_container' >\n                                        <input type='text' name='input_90.2' id='input_4_90_2' value=''     aria-required='false'   \/>\n                                        <label for='input_4_90_2' id='input_4_90_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_90_3_container' >\n                                    <input type='text' name='input_90.3' id='input_4_90_3' value=''    aria-required='false'    \/>\n                                    <label for='input_4_90_3' id='input_4_90_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_4_90_4_container' >\n                                        <input type='text' name='input_90.4' id='input_4_90_4' value=''      aria-required='false'    \/>\n                                        <label for='input_4_90_4' id='input_4_90_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_4_90_5_container' >\n                                    <input type='text' name='input_90.5' id='input_4_90_5' value=''    aria-required='false'    \/>\n                                    <label for='input_4_90_5' id='input_4_90_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_4_90_6_container' >\n                                        <select name='input_90.6' id='input_4_90_6'   aria-required='false'    ><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_4_90_6' id='input_4_90_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><fieldset id=\"field_4_44\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>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_4_44' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_44_1_container' >\n                                        <input type='text' name='input_44.1' id='input_4_44_1' value=''    aria-required='true'    \/>\n                                        <label for='input_4_44_1' id='input_4_44_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_4_44_3_container' >\n                                    <input type='text' name='input_44.3' id='input_4_44_3' value=''    aria-required='true'    \/>\n                                    <label for='input_4_44_3' id='input_4_44_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_4_44_4_container' >\n                                        <input type='text' name='input_44.4' id='input_4_44_4' value=''      aria-required='true'    \/>\n                                        <label for='input_4_44_4' id='input_4_44_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_4_44_5_container' >\n                                    <input type='text' name='input_44.5' id='input_4_44_5' value=''    aria-required='true'    \/>\n                                    <label for='input_4_44_5' id='input_4_44_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_4_44_6_container' >\n                                        <select name='input_44.6' id='input_4_44_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_4_44_6' id='input_4_44_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_44\" 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_4_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_4_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_4_5' class='gform_page' data-js='page-field-id-69' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_42\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"form-title\">BOOKING INFORMATION <\/h3><\/div><fieldset id=\"field_4_20\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Home Visit Requested<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_20'><div class='gchoice gchoice_4_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='General Practice\/Primary Care'  id='choice_4_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_20_1' id='label_4_20_1' class='gform-field-label gform-field-label--type-inline'>General Practice\/Primary Care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='Specialistic Medicine'  id='choice_4_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_20_2' id='label_4_20_2' class='gform-field-label gform-field-label--type-inline'>Specialistic Medicine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='Acupuncture'  id='choice_4_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_20_3' id='label_4_20_3' class='gform-field-label gform-field-label--type-inline'>Acupuncture<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='Physiotherapy'  id='choice_4_20_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_20_4' id='label_4_20_4' class='gform-field-label gform-field-label--type-inline'>Physiotherapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_20_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.5' type='checkbox'  value='Podiatry\/Chiropody'  id='choice_4_20_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_20_5' id='label_4_20_5' class='gform-field-label gform-field-label--type-inline'>Podiatry\/Chiropody<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_20_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.6' type='checkbox'  value='Speech Therapy'  id='choice_4_20_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_20_6' id='label_4_20_6' class='gform-field-label gform-field-label--type-inline'>Speech Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_20_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.7' type='checkbox'  value='Psychology'  id='choice_4_20_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_20_7' id='label_4_20_7' class='gform-field-label gform-field-label--type-inline'>Psychology<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_20_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.8' type='checkbox'  value='Nursing Service'  id='choice_4_20_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_20_8' id='label_4_20_8' class='gform-field-label gform-field-label--type-inline'>Nursing Service<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_20_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.9' type='checkbox'  value='Midwifery'  id='choice_4_20_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_20_9' id='label_4_20_9' class='gform-field-label gform-field-label--type-inline'>Midwifery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_20_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.11' type='checkbox'  value='Nutritional Therapy'  id='choice_4_20_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_20_11' id='label_4_20_11' class='gform-field-label gform-field-label--type-inline'>Nutritional Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_63\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Online Service Requested<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_63'><div class='gchoice gchoice_4_63_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.1' type='checkbox'  value='General Practice\/Primary Care'  id='choice_4_63_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_63_1' id='label_4_63_1' class='gform-field-label gform-field-label--type-inline'>General Practice\/Primary Care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_63_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.2' type='checkbox'  value='Specialistic Medicine'  id='choice_4_63_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_63_2' id='label_4_63_2' class='gform-field-label gform-field-label--type-inline'>Specialistic Medicine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_63_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.3' type='checkbox'  value='Physiotherapy'  id='choice_4_63_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_63_3' id='label_4_63_3' class='gform-field-label gform-field-label--type-inline'>Physiotherapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_63_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.4' type='checkbox'  value='Speech Therapy'  id='choice_4_63_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_63_4' id='label_4_63_4' class='gform-field-label gform-field-label--type-inline'>Speech Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_63_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.5' type='checkbox'  value='Psychology'  id='choice_4_63_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_63_5' id='label_4_63_5' class='gform-field-label gform-field-label--type-inline'>Psychology<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_63_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.6' type='checkbox'  value='Midwifery'  id='choice_4_63_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_63_6' id='label_4_63_6' class='gform-field-label gform-field-label--type-inline'>Midwifery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_63_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.7' type='checkbox'  value='Nutritional Therapy'  id='choice_4_63_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_63_7' id='label_4_63_7' class='gform-field-label gform-field-label--type-inline'>Nutritional Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_17\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_17'><span class='gform-field-label__text'>Please provide details on the reason for your visit<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_4_17' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_78\" 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_visible\"  ><label class='gfield_label gform-field-label' for='input_4_78'><span class='gform-field-label__text'>PRESCRIPTION\/REFERRAL LETTER<\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='35840000' \/><input name='input_78' id='input_4_78' type='file' class='large' aria-describedby=\"gfield_upload_rules_4_78 gfield_description_4_78\" onchange='javascript:gformValidateFileSize( this, 35840000 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_78'>Max. file size: 34 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_4_78'><\/div> <\/div><div class='gfield_description' id='gfield_description_4_78'>Some services such as wound care, drug or IV administration, catheter care, stoma care and bowel care required a medical REFERRAL \/ PRESCRIPTION. Please attach your prescription here.<\/div><\/div><div id=\"field_4_21\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_21'><span class='gform-field-label__text'>Please let us know whether you have any preferences in terms of date and time for the visit.<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_4_21' class='textarea small'  aria-describedby=\"gfield_description_4_21\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_4_21'>Please provide as much detail as possible. This will allow us to better match you with the right Clinician<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_4_70' 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_4_70' 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_4_6' class='gform_page' data-js='page-field-id-70' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_61\" 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\"  ><label class='gfield_label gform-field-label' for='input_4_61'><span class='gform-field-label__text'>How do You Prefer to Pay for the visit?<\/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_61' id='input_4_61' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Credit\/Debit Card' >Credit\/Debit Card<\/option><option value='Paypal (surcharge applied)' >Paypal (surcharge applied)<\/option><option value='Bank Transfer' >Bank Transfer<\/option><option value='Voucher' >Voucher<\/option><\/select><\/div><\/div><div id=\"field_4_96\" 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\"  ><label class='gfield_label gform-field-label' for='input_4_96'><span class='gform-field-label__text'>Voucher Number<\/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_96' id='input_4_96' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_100\" 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\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_100'><span class='gform-field-label__text'>VOUCHER FOUND<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_4_100' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_98\" 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\"  ><!DOCTYPE html>\n<html lang=\"en\">\n<head>\n  <meta charset=\"UTF-8\" \/>\n  <title>Invalid Voucher<\/title>\n  <link href=\"https:\/\/fonts.googleapis.com\/css2?family=Raleway:wght@400;600&display=swap\" rel=\"stylesheet\">\n  <style>\n    .notice {\n      font-family: \"Raleway\", Arial, sans-serif;\n      font-size: 16px;\n      color: #ca1517;\n      text-align: justify;\n      margin: 0;\n    }\n  <\/style>\n<\/head>\n<body>\n  <p class=\"notice\">Sorry, this voucher number is not valid.<\/p>\n<\/body>\n<\/html><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_4_101' 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_4_101' 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_4_7' class='gform_page' data-js='page-field-id-101' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_4_29\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>How did you find us ?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_29'><div class='gchoice gchoice_4_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='GP\/Other Doctor'  id='choice_4_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_1' id='label_4_29_1' class='gform-field-label gform-field-label--type-inline'>GP\/Other Doctor<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='Word of mouth'  id='choice_4_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_2' id='label_4_29_2' class='gform-field-label gform-field-label--type-inline'>Word of mouth<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.3' type='checkbox'  value='Family\/Friends'  id='choice_4_29_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_3' id='label_4_29_3' class='gform-field-label gform-field-label--type-inline'>Family\/Friends<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.4' type='checkbox'  value='Hospital\/Clinic'  id='choice_4_29_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_4' id='label_4_29_4' class='gform-field-label gform-field-label--type-inline'>Hospital\/Clinic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.5' type='checkbox'  value='Insurance'  id='choice_4_29_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_5' id='label_4_29_5' class='gform-field-label gform-field-label--type-inline'>Insurance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.6' type='checkbox'  value='Search Engine'  id='choice_4_29_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_6' id='label_4_29_6' class='gform-field-label gform-field-label--type-inline'>Search Engine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.7' type='checkbox'  value='Leaflet'  id='choice_4_29_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_7' id='label_4_29_7' class='gform-field-label gform-field-label--type-inline'>Leaflet<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.8' type='checkbox'  value='Advertisement'  id='choice_4_29_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_8' id='label_4_29_8' class='gform-field-label gform-field-label--type-inline'>Advertisement<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_30\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Consent<\/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_30.1' id='input_4_30_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_4_30\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_30_1' ><span class='gform-field-label__text'>Acceptance of terms<\/span><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_30.2' value='Acceptance of terms' class='gform_hidden' \/><input type='hidden' name='input_30.3' value='1' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_4_30'><div class='gfield_consent_description_text' tabindex='0'>By selecting you are confirming that you have read and accepted our privacy policy in regards to treatment of your data.<\/div><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><button type='submit' id='gform_previous_button_4' 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='submit' id='gform_submit_button_4' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Send your Booking Request<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_4' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_4' id='gform_theme_4' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_4' id='gform_style_settings_4' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_4' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='4' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='EUR' value='eTMF3VsuaHfDzMKfdGWvuQCrGjcvZsi9l8Nl25MpyEm1vgcKBqOolo4zxA7rrDrXHHWHZWS+sPBCRdWGEXqy2GIh15Dpojci1N4eo07tTwsRylM=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_4' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_4' id='gform_target_page_number_4' value='2' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_4' id='gform_source_page_number_4' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n             <\/div><\/div>\n                        <\/form>\n                        <\/div><\/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;\">If a change or cancellation is communicated more than 48 hours* before the appointment, Medelit makes no charge for the service. If payment has already been made, a voucher for the value of the service is issued, valid for one year and usable for any further service (taxes and bank charges excluded). In case of two or more cancellations or rescheduling requests, or of a chargeback request on a card payment or a reverse bank transfer, Medelit reserves the right to charge &euro; 15.00 to cover administrative and bank costs for handling the cancelled or moved booking.<\/p>\n<p style=\"text-align: justify;\">If a cancellation or change is communicated within 24 hours* of the appointment time, or not communicated at all, 100% of the fee due for the service is charged.<\/p>\n<p style=\"text-align: justify;\">If a cancellation or change is communicated between 24 and 48 hours* before the appointment time, 50% of the service is charged.<\/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;\">The same cancellation conditions apply to the visits included in pre-purchased cycles or packages at discounted rates. If a discounted package is cancelled part-way through, any voucher issued for the unused sessions is calculated at the full fee of the services already used.<\/p>\n<p style=\"text-align: justify;\"><strong>Blood draws and swabs at home, video consultations and telephone consultations follow a different rule:<\/strong> if a cancellation or change is communicated within 48 hours of the appointment time, or not communicated at all, 100% of the fee due for the service is charged.<\/p>\n<p style=\"text-align: justify;\">* Weekends and public holidays are excluded when counting the hours.<\/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 the conditions above.<\/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 the cancellation conditions above.<\/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 CONTACT US FOR 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 us directly if you need to change or cancel a confirmed appointment. It is a single point of contact, available at any time, and it informs us immediately.<\/p>\n<p style=\"text-align: justify;\">If you ask to change the time of an appointment we do our 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 the cancellation conditions apply.<\/p>\n<p style=\"text-align: justify;\">You can also write to us at prenotazioni@medelit.com.<\/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 v28.4 - 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