{"id":11023,"date":"2021-03-17T12:24:44","date_gmt":"2021-03-17T12:24:44","guid":{"rendered":"https:\/\/www.medelit.com\/it-en\/?p=11023"},"modified":"2026-06-15T23:11:22","modified_gmt":"2026-06-15T21:11:22","slug":"book-a-covid-19-test-in-italy","status":"publish","type":"post","link":"https:\/\/www.medelit.com\/it-en\/book-a-covid-19-test-in-italy\/","title":{"rendered":"Book a COVID 19 Test in ITALY"},"content":{"rendered":"<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 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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_7' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">COVID 19 Test BOOKING<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_7'  action='\/it-en\/wp-json\/wp\/v2\/posts\/11023#gf_7' data-formid='7' novalidate>\n        <div id='gf_progressbar_wrapper_7' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>10<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_red' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_red percentbar_10' style='width:10%;'><span>10%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_7_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_7_147\" 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_7_147'>Company<\/label><div class='ginput_container'><input name='input_147' id='input_7_147' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_7_147'>This field is for validation purposes and should be left unchanged.<\/div><\/li><li id=\"field_7_111\" class=\"gfield gfield--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\"  ><p class=\"form-title\" style=\"text-align: justify;\"><strong>Notice - Before you start your Booking <\/strong><\/p> We carry out PCR and Rapid Antigen Tests in your HOME, HOTEL or WORKPLACE<\/p> \n<p class=\"form-title\" style=\"text-align: justify;\"> Rapid Antigen Tests provide results on-site, within 15 -20 minutes. \n PCR Tests are sent to our certified partnered labs. We can normally provide results for both PCR swabs and antibody tests within 12-48 hours (depending on the area), but may experience delays that are not directly dependent on us (example increased lab workload or disruption of courier services) and for which we cannot be made responsible. As soon as we receive the test results from the lab, we will send these over to you and give you a call to inform you that your results are ready.<\/p><\/li><li id=\"field_7_133\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full 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' >Have your received confirmation that the SERVICE IS ACTIVE at your address?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_7_133'>PLEASE TAKE NOTICE - This is not an enquiry form. Please do NOT use this form prior to contacting us for confirmation of cover and fees at your address. <\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_133'>\n\t\t\t<li class='gchoice gchoice_7_133_0'>\n\t\t\t\t<input name='input_133' type='radio' value='YES'  id='choice_7_133_0'    \/>\n\t\t\t\t<label for='choice_7_133_0' id='label_7_133_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_133_1'>\n\t\t\t\t<input name='input_133' type='radio' value='NO'  id='choice_7_133_1'    \/>\n\t\t\t\t<label for='choice_7_133_1' id='label_7_133_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_134\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Have you received information on REPORT TIMING of COVID tests?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_134'>\n\t\t\t<li class='gchoice gchoice_7_134_0'>\n\t\t\t\t<input name='input_134' type='radio' value='YES'  id='choice_7_134_0'    \/>\n\t\t\t\t<label for='choice_7_134_0' id='label_7_134_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_134_1'>\n\t\t\t\t<input name='input_134' type='radio' value='NO'  id='choice_7_134_1'    \/>\n\t\t\t\t<label for='choice_7_134_1' id='label_7_134_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_135\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Have you already received information on the FEES for the service at your address?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_135'>\n\t\t\t<li class='gchoice gchoice_7_135_0'>\n\t\t\t\t<input name='input_135' type='radio' value='YES'  id='choice_7_135_0'    \/>\n\t\t\t\t<label for='choice_7_135_0' id='label_7_135_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_135_1'>\n\t\t\t\t<input name='input_135' type='radio' value='NO'  id='choice_7_135_1'    \/>\n\t\t\t\t<label for='choice_7_135_1' id='label_7_135_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_23\" class=\"gfield gfield--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\"  ><h3 class=\"form-title\">SORRY, WE ARE UNABLE TO PROCESS THIS BOOKING <\/p>\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. <\/p>\nIf you need information on our COVID tests or any of our services, please contact us via chat, send us an enquiry form through here: https:\/\/www.medelit.com\/it-en\/request-house-call\/request-information\/, or call us at +39 02 87 366 070 prior to using this booking form.<\/h3><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_7_142' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_2' class='gform_page' data-js='page-field-id-142' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_7_112\" class=\"gfield gfield--type-radio gfield--type-choice 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' >I am a<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_112'>\n\t\t\t<li class='gchoice gchoice_7_112_0'>\n\t\t\t\t<input name='input_112' type='radio' value='Returning Patient'  id='choice_7_112_0'    \/>\n\t\t\t\t<label for='choice_7_112_0' id='label_7_112_0' class='gform-field-label gform-field-label--type-inline'>Returning Patient<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_112_1'>\n\t\t\t\t<input name='input_112' type='radio' value='New to Medelit'  id='choice_7_112_1'    \/>\n\t\t\t\t<label for='choice_7_112_1' id='label_7_112_1' class='gform-field-label gform-field-label--type-inline'>New to Medelit<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_54\" class=\"gfield gfield--type-radio gfield--type-choice 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' >The test I am asking is for<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_7_54'>If you are requesting the COVID19 test for more than one person, please take notice you will need all their information to complete this form.<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_54'>\n\t\t\t<li class='gchoice gchoice_7_54_0'>\n\t\t\t\t<input name='input_54' type='radio' value='For myself Only'  id='choice_7_54_0'    \/>\n\t\t\t\t<label for='choice_7_54_0' id='label_7_54_0' class='gform-field-label gform-field-label--type-inline'>For myself Only<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_54_1'>\n\t\t\t\t<input name='input_54' type='radio' value='For more than 1 person (same address)'  id='choice_7_54_1'    \/>\n\t\t\t\t<label for='choice_7_54_1' id='label_7_54_1' class='gform-field-label gform-field-label--type-inline'>For more than 1 person (same address)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_1\" class=\"gfield gfield--type-name 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 gfield_label_before_complex' >Your Name and Surname<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_7_1'>\n                            \n                            <span id='input_7_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_7_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_7_1_3' class='gform-field-label gform-field-label--type-sub '>Name (and any second name)<\/label>\n                                                <\/span>\n                            \n                            <span id='input_7_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_7_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_7_1_6' class='gform-field-label gform-field-label--type-sub '>Surname<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_2\" class=\"gfield gfield--type-email 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_7_2'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_7_2' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_7_3\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_3'>Phone 1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_7_3' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_7_3\"  \/><\/div><div class='gfield_description' id='gfield_description_7_3'>We highly recommend that you leave us 2 phone numbers.<\/div><\/li><li id=\"field_7_4\" class=\"gfield gfield--type-phone field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_4'>Mobile \/ Telephone 2<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_7_4' type='tel' value='' class='medium'    aria-invalid=\"false\" aria-describedby=\"gfield_description_7_4\"  \/><\/div><div class='gfield_description' id='gfield_description_7_4'>If you can, do leave us a second phone number so as to be sure we can contact you in case of need at the time of your appointment.<\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_19' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Go Back'  \/> <input type='button' id='gform_next_button_7_19' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_3' class='gform_page' data-js='page-field-id-19' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_7_127\" class=\"gfield gfield--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\"  ><h2 class=\"form-title\">ADDRESS WHERE YOU NEED US TO CARRY OUR THE SWAB<\/h2><\/li><li id=\"field_7_114\" class=\"gfield gfield--type-address 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 gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip has_country ginput_container_address gform-grid-row' id='input_7_114' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_114_1_container' >\n                                        <input type='text' name='input_114.1' id='input_7_114_1' value=''    aria-required='true'    \/>\n                                        <label for='input_7_114_1' id='input_7_114_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_7_114_3_container' >\n                                    <input type='text' name='input_114.3' id='input_7_114_3' value=''    aria-required='true'    \/>\n                                    <label for='input_7_114_3' id='input_7_114_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_114.4' id='input_7_114_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_7_114_5_container' >\n                                    <input type='text' name='input_114.5' id='input_7_114_5' value=''    aria-required='true'    \/>\n                                    <label for='input_7_114_5' id='input_7_114_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_7_114_6_container' >\n                                        <select name='input_114.6' id='input_7_114_6'   aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' selected='selected'>Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_7_114_6' id='input_7_114_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><\/li><li id=\"field_7_145\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_145'>Street Level Intercom<\/label><div class='ginput_container ginput_container_text'><input name='input_145' id='input_7_145' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_146\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_146'>Floor Number<\/label><div class='ginput_container ginput_container_text'><input name='input_146' id='input_7_146' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_20' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Go Back'  \/> <input type='button' id='gform_next_button_7_20' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_4' class='gform_page' data-js='page-field-id-20' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_7_21\" class=\"gfield gfield--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\"  ><h2 class=\"form-title\">BILLING ADDRESS INFORMATION <\/h2><\/li><li id=\"field_7_12\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Is the Home Visit Address the same as Your Billing Address?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_12'>\n\t\t\t<li class='gchoice gchoice_7_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='Yes'  id='choice_7_12_0'    \/>\n\t\t\t\t<label for='choice_7_12_0' id='label_7_12_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_12_1'>\n\t\t\t\t<input name='input_12' type='radio' value='No'  id='choice_7_12_1'    \/>\n\t\t\t\t<label for='choice_7_12_1' id='label_7_12_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_115\" class=\"gfield gfield--type-address 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 gfield_label_before_complex' >Billing Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip has_country ginput_container_address gform-grid-row' id='input_7_115' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_115_1_container' >\n                                        <input type='text' name='input_115.1' id='input_7_115_1' value=''    aria-required='true'    \/>\n                                        <label for='input_7_115_1' id='input_7_115_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_7_115_2_container' >\n                                        <input type='text' name='input_115.2' id='input_7_115_2' value=''     aria-required='false'   \/>\n                                        <label for='input_7_115_2' id='input_7_115_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_7_115_3_container' >\n                                    <input type='text' name='input_115.3' id='input_7_115_3' value=''    aria-required='true'    \/>\n                                    <label for='input_7_115_3' id='input_7_115_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_115.4' id='input_7_115_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_7_115_5_container' >\n                                    <input type='text' name='input_115.5' id='input_7_115_5' value=''    aria-required='true'    \/>\n                                    <label for='input_7_115_5' id='input_7_115_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_7_115_6_container' >\n                                        <select name='input_115.6' id='input_7_115_6'   aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' selected='selected'>Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_7_115_6' id='input_7_115_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><\/li><li id=\"field_7_79\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon 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_7_79'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_79' id='input_7_79' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_7_79_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_7_79_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_79' class='gform_hidden' value='https:\/\/www.medelit.com\/it-en\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_22' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Go Back'  \/> <input type='button' id='gform_next_button_7_22' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_5' class='gform_page' data-js='page-field-id-22' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_7_34\" class=\"gfield gfield--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\"  ><h2 class=\"form-title\">SHORT TRIAGE <\/h2><\/li><li id=\"field_7_103\" class=\"gfield gfield--type-checkbox gfield--type-choice 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 gfield_label_before_complex' >During the Last 2 Weeks have you Experienced:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_7_103'><li class='gchoice gchoice_7_103_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.1' type='checkbox'  value='No Symptoms'  id='choice_7_103_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_103_1' id='label_7_103_1' class='gform-field-label gform-field-label--type-inline'>No Symptoms<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_103_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.2' type='checkbox'  value='Fever (&gt; 37\u00b0C)'  id='choice_7_103_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_103_2' id='label_7_103_2' class='gform-field-label gform-field-label--type-inline'>Fever (> 37\u00b0C)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_103_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.3' type='checkbox'  value='Cough'  id='choice_7_103_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_103_3' id='label_7_103_3' class='gform-field-label gform-field-label--type-inline'>Cough<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_103_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.4' type='checkbox'  value='Shortness of Breath\/Breathing Difficulties'  id='choice_7_103_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_103_4' id='label_7_103_4' class='gform-field-label gform-field-label--type-inline'>Shortness of Breath\/Breathing Difficulties<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_103_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.5' type='checkbox'  value='Cold\/Congestion'  id='choice_7_103_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_103_5' id='label_7_103_5' class='gform-field-label gform-field-label--type-inline'>Cold\/Congestion<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_103_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.6' type='checkbox'  value='Sore Throat'  id='choice_7_103_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_103_6' id='label_7_103_6' class='gform-field-label gform-field-label--type-inline'>Sore Throat<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_103_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.7' type='checkbox'  value='Tummy problems'  id='choice_7_103_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_103_7' id='label_7_103_7' class='gform-field-label gform-field-label--type-inline'>Tummy problems<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_103_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.8' type='checkbox'  value='Conjunctivitis \/ Red or Sore Eyes'  id='choice_7_103_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_103_8' id='label_7_103_8' class='gform-field-label gform-field-label--type-inline'>Conjunctivitis \/ Red or Sore Eyes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_103_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.9' type='checkbox'  value='Reduced Sense of Smell and\/or Taste'  id='choice_7_103_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_103_9' id='label_7_103_9' class='gform-field-label gform-field-label--type-inline'>Reduced Sense of Smell and\/or Taste<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_103_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.11' type='checkbox'  value='Flu-like Symptoms (muscle aches\/pain, tiredness, shivering)'  id='choice_7_103_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_103_11' id='label_7_103_11' class='gform-field-label gform-field-label--type-inline'>Flu-like Symptoms (muscle aches\/pain, tiredness, shivering)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_46\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Have you recently come in contact with anyone presenting COVID19 symptoms or positive at a COVID19 Test?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_46'>\n\t\t\t<li class='gchoice gchoice_7_46_0'>\n\t\t\t\t<input name='input_46' type='radio' value='Yes'  id='choice_7_46_0'    \/>\n\t\t\t\t<label for='choice_7_46_0' id='label_7_46_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_46_1'>\n\t\t\t\t<input name='input_46' type='radio' value='No'  id='choice_7_46_1'    \/>\n\t\t\t\t<label for='choice_7_46_1' id='label_7_46_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_136\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Are you Vaccinated?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_136'>\n\t\t\t<li class='gchoice gchoice_7_136_0'>\n\t\t\t\t<input name='input_136' type='radio' value='YES, 1ST DOSE ONLY'  id='choice_7_136_0'    \/>\n\t\t\t\t<label for='choice_7_136_0' id='label_7_136_0' class='gform-field-label gform-field-label--type-inline'>YES, 1ST DOSE ONLY<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_136_1'>\n\t\t\t\t<input name='input_136' type='radio' value='YES, 2 DOSES'  id='choice_7_136_1'    \/>\n\t\t\t\t<label for='choice_7_136_1' id='label_7_136_1' class='gform-field-label gform-field-label--type-inline'>YES, 2 DOSES<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_136_2'>\n\t\t\t\t<input name='input_136' type='radio' value='YES, 3 DOSES'  id='choice_7_136_2'    \/>\n\t\t\t\t<label for='choice_7_136_2' id='label_7_136_2' class='gform-field-label gform-field-label--type-inline'>YES, 3 DOSES<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_136_3'>\n\t\t\t\t<input name='input_136' type='radio' value='NO'  id='choice_7_136_3'    \/>\n\t\t\t\t<label for='choice_7_136_3' id='label_7_136_3' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_52' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Go Back'  \/> <input type='button' id='gform_next_button_7_52' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_6' class='gform_page' data-js='page-field-id-52' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_7_25\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Type of COVID 19 Test<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_25'>\n\t\t\t<li class='gchoice gchoice_7_25_0'>\n\t\t\t\t<input name='input_25' type='radio' value='PCR Swab'  id='choice_7_25_0'    \/>\n\t\t\t\t<label for='choice_7_25_0' id='label_7_25_0' class='gform-field-label gform-field-label--type-inline'>PCR Swab<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_25_1'>\n\t\t\t\t<input name='input_25' type='radio' value='Rapid Antigen COVID-19 Swab'  id='choice_7_25_1'    \/>\n\t\t\t\t<label for='choice_7_25_1' id='label_7_25_1' class='gform-field-label gform-field-label--type-inline'>Rapid Antigen COVID-19 Swab<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_25_2'>\n\t\t\t\t<input name='input_25' type='radio' value='COVID-19 Antibody Test (Blood sample)'  id='choice_7_25_2'    \/>\n\t\t\t\t<label for='choice_7_25_2' id='label_7_25_2' class='gform-field-label gform-field-label--type-inline'>COVID-19 Antibody Test (Blood sample)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you wish to add a Video-Consultation with one of our Doctors to discuss which Test you should take and\/or Discuss your Test Results?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_30'>\n\t\t\t<li class='gchoice gchoice_7_30_0'>\n\t\t\t\t<input name='input_30' type='radio' value='Yes, I wish to add a video-consultation with a Medelit Doctor'  id='choice_7_30_0'    \/>\n\t\t\t\t<label for='choice_7_30_0' id='label_7_30_0' class='gform-field-label gform-field-label--type-inline'>Yes, I wish to add a video-consultation with a Medelit Doctor<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_30_1'>\n\t\t\t\t<input name='input_30' type='radio' value='No, I will talk to my GP'  id='choice_7_30_1'    \/>\n\t\t\t\t<label for='choice_7_30_1' id='label_7_30_1' class='gform-field-label gform-field-label--type-inline'>No, I will talk to my GP<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_7_30'>The additional fee for this service is of 87 \u00a3.<\/div><\/li><li id=\"field_7_55\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_55'>Preferred Date and\/or Time for the Nurse Appointment<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_7_55' type='text' value='' class='medium' maxlength='100' aria-describedby=\"gfield_description_7_55\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_7_55'>We will do our best to accommodate your request. <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_80' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Go Back'  \/> <input type='button' id='gform_next_button_7_80' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_7' class='gform_page' data-js='page-field-id-80' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_7_101\" class=\"gfield gfield--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\"  ><h2 class=\"form-title\">SECOND PERSON INFORMATION<\/h2><\/li><li id=\"field_7_116\" class=\"gfield gfield--type-name 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 gfield_label_before_complex' >SECOND PERSON Name and Surname<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_7_116'>\n                            \n                            <span id='input_7_116_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_116.3' id='input_7_116_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_7_116_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_7_116_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_116.6' id='input_7_116_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_7_116_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_85\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Is this SECOND test included in the same Invoice?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_85'>\n\t\t\t<li class='gchoice gchoice_7_85_0'>\n\t\t\t\t<input name='input_85' type='radio' value='Yes'  id='choice_7_85_0'    \/>\n\t\t\t\t<label for='choice_7_85_0' id='label_7_85_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_85_1'>\n\t\t\t\t<input name='input_85' type='radio' value='No'  id='choice_7_85_1'    \/>\n\t\t\t\t<label for='choice_7_85_1' id='label_7_85_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_117\" class=\"gfield gfield--type-address 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 gfield_label_before_complex' >SECOND PERSON Billing Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip has_country ginput_container_address gform-grid-row' id='input_7_117' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_117_1_container' >\n                                        <input type='text' name='input_117.1' id='input_7_117_1' value=''    aria-required='true'    \/>\n                                        <label for='input_7_117_1' id='input_7_117_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_7_117_3_container' >\n                                    <input type='text' name='input_117.3' id='input_7_117_3' value=''    aria-required='true'    \/>\n                                    <label for='input_7_117_3' id='input_7_117_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_117.4' id='input_7_117_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_7_117_5_container' >\n                                    <input type='text' name='input_117.5' id='input_7_117_5' value=''    aria-required='true'    \/>\n                                    <label for='input_7_117_5' id='input_7_117_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_7_117_6_container' >\n                                        <select name='input_117.6' id='input_7_117_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_7_117_6' id='input_7_117_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><\/li><li id=\"field_7_109\" class=\"gfield gfield--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_7_109'>SECOND PERSON Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_7_109' type='text' value='' class='medium' maxlength='30'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_84\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon 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_7_84'>SECOND PERSON Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_84' id='input_7_84' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_7_84_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_7_84_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_84' class='gform_hidden' value='https:\/\/www.medelit.com\/it-en\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_7_118\" class=\"gfield gfield--type-radio gfield--type-choice 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' >SECOND PERSON INFO: Have you recently come in contact with anyone presenting COVID19 symptoms or positive at a COVID19 Test?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_118'>\n\t\t\t<li class='gchoice gchoice_7_118_0'>\n\t\t\t\t<input name='input_118' type='radio' value='Yes'  id='choice_7_118_0'    \/>\n\t\t\t\t<label for='choice_7_118_0' id='label_7_118_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_118_1'>\n\t\t\t\t<input name='input_118' type='radio' value='No'  id='choice_7_118_1'    \/>\n\t\t\t\t<label for='choice_7_118_1' id='label_7_118_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_119\" class=\"gfield gfield--type-checkbox gfield--type-choice 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 gfield_label_before_complex' >SECOND PERSON TESTED - During the Last 2 Weeks have you Experienced:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_7_119'><li class='gchoice gchoice_7_119_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_119.1' type='checkbox'  value='No Symptoms'  id='choice_7_119_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_119_1' id='label_7_119_1' class='gform-field-label gform-field-label--type-inline'>No Symptoms<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_119_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_119.2' type='checkbox'  value='Fever (&gt; 37\u00b0C)'  id='choice_7_119_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_119_2' id='label_7_119_2' class='gform-field-label gform-field-label--type-inline'>Fever (> 37\u00b0C)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_119_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_119.3' type='checkbox'  value='Cough'  id='choice_7_119_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_119_3' id='label_7_119_3' class='gform-field-label gform-field-label--type-inline'>Cough<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_119_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_119.4' type='checkbox'  value='Shortness of Breath\/Breathing Difficulties'  id='choice_7_119_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_119_4' id='label_7_119_4' class='gform-field-label gform-field-label--type-inline'>Shortness of Breath\/Breathing Difficulties<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_119_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_119.5' type='checkbox'  value='Cold\/Congestion'  id='choice_7_119_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_119_5' id='label_7_119_5' class='gform-field-label gform-field-label--type-inline'>Cold\/Congestion<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_119_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_119.6' type='checkbox'  value='Sore Throat'  id='choice_7_119_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_119_6' id='label_7_119_6' class='gform-field-label gform-field-label--type-inline'>Sore Throat<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_119_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_119.7' type='checkbox'  value='Tummy problems'  id='choice_7_119_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_119_7' id='label_7_119_7' class='gform-field-label gform-field-label--type-inline'>Tummy problems<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_119_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_119.8' type='checkbox'  value='Conjunctivitis \/ Red or Sore Eyes'  id='choice_7_119_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_119_8' id='label_7_119_8' class='gform-field-label gform-field-label--type-inline'>Conjunctivitis \/ Red or Sore Eyes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_119_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_119.9' type='checkbox'  value='Reduced Sense of Smell and\/or Taste'  id='choice_7_119_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_119_9' id='label_7_119_9' class='gform-field-label gform-field-label--type-inline'>Reduced Sense of Smell and\/or Taste<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_119_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_119.11' type='checkbox'  value='Flu-like Symptoms (muscle aches\/pain, tiredness, shivering)'  id='choice_7_119_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_119_11' id='label_7_119_11' class='gform-field-label gform-field-label--type-inline'>Flu-like Symptoms (muscle aches\/pain, tiredness, shivering)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_137\" class=\"gfield gfield--type-radio gfield--type-choice 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' >SECOND PERSON Are you Vaccinated?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_137'>\n\t\t\t<li class='gchoice gchoice_7_137_0'>\n\t\t\t\t<input name='input_137' type='radio' value='YES, 1ST DOSE ONLY'  id='choice_7_137_0'    \/>\n\t\t\t\t<label for='choice_7_137_0' id='label_7_137_0' class='gform-field-label gform-field-label--type-inline'>YES, 1ST DOSE ONLY<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_137_1'>\n\t\t\t\t<input name='input_137' type='radio' value='YES, 2 DOSES'  id='choice_7_137_1'    \/>\n\t\t\t\t<label for='choice_7_137_1' id='label_7_137_1' class='gform-field-label gform-field-label--type-inline'>YES, 2 DOSES<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_137_2'>\n\t\t\t\t<input name='input_137' type='radio' value='YES, 3 DOSES'  id='choice_7_137_2'    \/>\n\t\t\t\t<label for='choice_7_137_2' id='label_7_137_2' class='gform-field-label gform-field-label--type-inline'>YES, 3 DOSES<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_137_3'>\n\t\t\t\t<input name='input_137' type='radio' value='NO'  id='choice_7_137_3'    \/>\n\t\t\t\t<label for='choice_7_137_3' id='label_7_137_3' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_87\" class=\"gfield gfield--type-radio gfield--type-choice 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' >ADD A THIRD TEST<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_87'>\n\t\t\t<li class='gchoice gchoice_7_87_0'>\n\t\t\t\t<input name='input_87' type='radio' value='Yes'  id='choice_7_87_0'    \/>\n\t\t\t\t<label for='choice_7_87_0' id='label_7_87_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_87_1'>\n\t\t\t\t<input name='input_87' type='radio' value='No'  id='choice_7_87_1'    \/>\n\t\t\t\t<label for='choice_7_87_1' id='label_7_87_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_100' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Go Back'  \/> <input type='button' id='gform_next_button_7_100' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_8' class='gform_page' data-js='page-field-id-100' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_7_102\" class=\"gfield gfield--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\"  ><h2 class=\"form-title\">THIRD PERSON<\/h2><\/li><li id=\"field_7_120\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >THIRD PERSON Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_7_120'>\n                            \n                            <span id='input_7_120_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_120.3' id='input_7_120_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_7_120_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_7_120_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_120.6' id='input_7_120_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_7_120_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_121\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Is this THIRD test included in the same Invoice?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_121'>\n\t\t\t<li class='gchoice gchoice_7_121_0'>\n\t\t\t\t<input name='input_121' type='radio' value='Yes'  id='choice_7_121_0'    \/>\n\t\t\t\t<label for='choice_7_121_0' id='label_7_121_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_121_1'>\n\t\t\t\t<input name='input_121' type='radio' value='No'  id='choice_7_121_1'    \/>\n\t\t\t\t<label for='choice_7_121_1' id='label_7_121_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_122\" class=\"gfield gfield--type-address 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 gfield_label_before_complex' >THIRD PERSON Billing Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip has_country ginput_container_address gform-grid-row' id='input_7_122' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_122_1_container' >\n                                        <input type='text' name='input_122.1' id='input_7_122_1' value=''    aria-required='true'    \/>\n                                        <label for='input_7_122_1' id='input_7_122_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_7_122_3_container' >\n                                    <input type='text' name='input_122.3' id='input_7_122_3' value=''    aria-required='true'    \/>\n                                    <label for='input_7_122_3' id='input_7_122_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_122.4' id='input_7_122_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_7_122_5_container' >\n                                    <input type='text' name='input_122.5' id='input_7_122_5' value=''    aria-required='true'    \/>\n                                    <label for='input_7_122_5' id='input_7_122_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_7_122_6_container' >\n                                        <select name='input_122.6' id='input_7_122_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_7_122_6' id='input_7_122_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><\/li><li id=\"field_7_110\" class=\"gfield gfield--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_7_110'>THIRD PERSON Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_7_110' type='text' value='' class='medium' maxlength='50'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_94\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon 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_7_94'>THIRD PERSON Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_94' id='input_7_94' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_7_94_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_7_94_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_94' class='gform_hidden' value='https:\/\/www.medelit.com\/it-en\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_140' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_7_140' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_9' class='gform_page' data-js='page-field-id-140' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_7_141\" class=\"gfield gfield--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\"  ><h2 class=\"form-title\">THIRD PERSON<\/h2><\/li><li id=\"field_7_139\" class=\"gfield gfield--type-radio gfield--type-choice 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' >THIRD PERSON TESTED INFO: Have you recently come in contact with anyone presenting COVID19 symptoms or positive at a COVID19 Test?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_139'>\n\t\t\t<li class='gchoice gchoice_7_139_0'>\n\t\t\t\t<input name='input_139' type='radio' value='Yes'  id='choice_7_139_0'    \/>\n\t\t\t\t<label for='choice_7_139_0' id='label_7_139_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_139_1'>\n\t\t\t\t<input name='input_139' type='radio' value='No'  id='choice_7_139_1'    \/>\n\t\t\t\t<label for='choice_7_139_1' id='label_7_139_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_123\" class=\"gfield gfield--type-checkbox gfield--type-choice 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 gfield_label_before_complex' >THIRD PERSON TESTED - During the Last 2 Weeks have you Experienced:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_7_123'><li class='gchoice gchoice_7_123_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.1' type='checkbox'  value='No Symptoms'  id='choice_7_123_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_123_1' id='label_7_123_1' class='gform-field-label gform-field-label--type-inline'>No Symptoms<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_123_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.2' type='checkbox'  value='Fever (&gt; 37\u00b0C)'  id='choice_7_123_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_123_2' id='label_7_123_2' class='gform-field-label gform-field-label--type-inline'>Fever (> 37\u00b0C)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_123_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.3' type='checkbox'  value='Cough'  id='choice_7_123_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_123_3' id='label_7_123_3' class='gform-field-label gform-field-label--type-inline'>Cough<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_123_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.4' type='checkbox'  value='Shortness of Breath\/Breathing Difficulties'  id='choice_7_123_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_123_4' id='label_7_123_4' class='gform-field-label gform-field-label--type-inline'>Shortness of Breath\/Breathing Difficulties<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_123_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.5' type='checkbox'  value='Cold\/Congestion'  id='choice_7_123_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_123_5' id='label_7_123_5' class='gform-field-label gform-field-label--type-inline'>Cold\/Congestion<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_123_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.6' type='checkbox'  value='Sore Throat'  id='choice_7_123_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_123_6' id='label_7_123_6' class='gform-field-label gform-field-label--type-inline'>Sore Throat<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_123_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.7' type='checkbox'  value='Tummy problems'  id='choice_7_123_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_123_7' id='label_7_123_7' class='gform-field-label gform-field-label--type-inline'>Tummy problems<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_123_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.8' type='checkbox'  value='Conjunctivitis \/ Red or Sore Eyes'  id='choice_7_123_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_123_8' id='label_7_123_8' class='gform-field-label gform-field-label--type-inline'>Conjunctivitis \/ Red or Sore Eyes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_123_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.9' type='checkbox'  value='Reduced Sense of Smell and\/or Taste'  id='choice_7_123_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_123_9' id='label_7_123_9' class='gform-field-label gform-field-label--type-inline'>Reduced Sense of Smell and\/or Taste<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_7_123_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.11' type='checkbox'  value='Flu-like Symptoms (muscle aches\/pain, tiredness, shivering)'  id='choice_7_123_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_123_11' id='label_7_123_11' class='gform-field-label gform-field-label--type-inline'>Flu-like Symptoms (muscle aches\/pain, tiredness, shivering)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_138\" class=\"gfield gfield--type-radio gfield--type-choice 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' >THIRD PERSON Are you Vaccinated?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_138'>\n\t\t\t<li class='gchoice gchoice_7_138_0'>\n\t\t\t\t<input name='input_138' type='radio' value='YES, 1ST DOSE ONLY'  id='choice_7_138_0'    \/>\n\t\t\t\t<label for='choice_7_138_0' id='label_7_138_0' class='gform-field-label gform-field-label--type-inline'>YES, 1ST DOSE ONLY<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_138_1'>\n\t\t\t\t<input name='input_138' type='radio' value='YES, 2 DOSES'  id='choice_7_138_1'    \/>\n\t\t\t\t<label for='choice_7_138_1' id='label_7_138_1' class='gform-field-label gform-field-label--type-inline'>YES, 2 DOSES<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_138_2'>\n\t\t\t\t<input name='input_138' type='radio' value='YES, 3 DOSES'  id='choice_7_138_2'    \/>\n\t\t\t\t<label for='choice_7_138_2' id='label_7_138_2' class='gform-field-label gform-field-label--type-inline'>YES, 3 DOSES<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_138_3'>\n\t\t\t\t<input name='input_138' type='radio' value='NO'  id='choice_7_138_3'    \/>\n\t\t\t\t<label for='choice_7_138_3' id='label_7_138_3' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_143' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_7_143' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_10' class='gform_page' data-js='page-field-id-143' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_7_144\" class=\"gfield gfield--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' 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