{"id":427,"date":"2016-11-21T17:48:57","date_gmt":"2016-11-21T17:48:57","guid":{"rendered":"http:\/\/www.medelit.com\/uk\/?page_id=427"},"modified":"2025-08-12T09:10:04","modified_gmt":"2025-08-12T08:10:04","slug":"book-home-visit","status":"publish","type":"page","link":"https:\/\/www.medelit.com\/uk\/contact-us\/book-home-visit\/","title":{"rendered":"Book a Home or Online Visit"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container fusion-parallax-fixed hundred-percent-fullwidth non-hundred-percent-height-scrolling lazyload\" style=\"--awb-background-position:left top;--awb-border-sizes-top:0px;--awb-border-sizes-bottom:0px;--awb-border-sizes-left:0px;--awb-border-sizes-right:0px;--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:10px;--awb-padding-right:30px;--awb-padding-bottom:50px;--awb-padding-left:30px;--awb-background-size:cover;--awb-flex-wrap:wrap;background-attachment:fixed;\" data-bg=\"https:\/\/www.medelit.com\/it\/wp-content\/uploads\/sites\/2\/2015\/12\/Screen-Shot-2016-05-13-at-20.45.08-1024x575.png\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:calc( 100% + 0px ) !important;max-width:calc( 100% + 0px ) !important;margin-left: calc(-0px \/ 2 );margin-right: calc(-0px \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:40px;--awb-spacing-right-large:0px;--awb-margin-bottom-large:20px;--awb-spacing-left-large:0px;--awb-width-medium:100%;--awb-spacing-right-medium:0px;--awb-spacing-left-medium:0px;--awb-width-small:100%;--awb-spacing-right-small:0px;--awb-spacing-left-small:0px;\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-1\"><h1 style=\"text-align: center;\"><span style=\"font-family: georgia, palatino, serif;\"><span style=\"font-size: 36pt; color: #ffffff;\">BOOK A HOME OR ONLINE VISIT<\/span><\/span><\/h1>\n<\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:80PX;--awb-spacing-right-large:0px;--awb-margin-bottom-large:20px;--awb-spacing-left-large:0px;--awb-width-medium:100%;--awb-spacing-right-medium:0px;--awb-spacing-left-medium:0px;--awb-width-small:100%;--awb-spacing-right-small:0px;--awb-spacing-left-small:0px;\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-2\"><h2 style=\"text-align: justify;\"><span style=\"color: #ffffff; font-size: 14pt;\">Medelit House Call Medical Service<\/span><\/h2>\n<p style=\"text-align: justify;\"><span style=\"color: #ffffff; font-size: 14pt;\">The visit can be provided, according to your preferences, in your home, office, hotel or in any other appropriate place in which you might need our assistance.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"color: #ffffff; font-size: 14pt;\">Medelit offers home visits and Online Services. All our services are available in central London and also cover various areas of greater London. Please feel free to use our online booking system to check availabilities and fees for your area.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"color: #ffffff; font-size: 14pt;\">Many of our professionals are available to visit also in areas that we do not usually cover (including other UK cities and even foreign countries). This will normally imply an extra cost to cover time and travel expenses. Please do not hesitate in contacting us for any out-of-area request. We will do all we can to assist you wherever you need us.<\/span><\/p>\n<h2 style=\"text-align: justify;\"><span style=\"color: #ffffff; font-size: 14pt;\">\u00a0<\/span><\/h2>\n<\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_1 1_1 fusion-flex-column fusion-flex-align-self-flex-start fusion-column-no-min-height\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:0px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:0px;--awb-width-medium:100%;--awb-spacing-right-medium:0px;--awb-spacing-left-medium:0px;--awb-width-small:100%;--awb-spacing-right-small:0px;--awb-spacing-left-small:0px;\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-3\"><p><span style=\"color: #ffffff; font-size: 14pt;\">Book a Home Visit or an Online Service with MEDELIT\u00a0 &#8211; It&#8217;s very simple<\/span><\/p>\n<p><span style=\"color: #ffffff; font-size: 14pt;\">You can book directly online:<\/span><\/p>\n<\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_4_5 4_5 fusion-flex-column\" style=\"--awb-padding-top:2px;--awb-padding-right:2px;--awb-padding-bottom:2px;--awb-padding-left:2px;--awb-bg-color:#ffffff;--awb-bg-color-hover:#ffffff;--awb-bg-size:cover;--awb-border-color:#f7f7f7;--awb-border-top:2px;--awb-border-right:2px;--awb-border-bottom:2px;--awb-border-left:2px;--awb-border-style:solid;--awb-width-large:80%;--awb-margin-top-large:0px;--awb-spacing-right-large:0px;--awb-margin-bottom-large:100px;--awb-spacing-left-large:0px;--awb-width-medium:80%;--awb-spacing-right-medium:0px;--awb-spacing-left-medium:0px;--awb-width-small:100%;--awb-spacing-right-small:0px;--awb-spacing-left-small:0px;\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"accordian fusion-accordian\" style=\"--awb-border-size:1px;--awb-icon-size:13px;--awb-content-font-size:16px;--awb-icon-alignment:left;--awb-hover-color:#f9f9f9;--awb-border-color:#cccccc;--awb-background-color:#ffffff;--awb-divider-color:#e0dede;--awb-divider-hover-color:#e0dede;--awb-icon-color:#ffffff;--awb-title-color:#ca1517;--awb-content-color:#000000;--awb-icon-box-color:#333333;--awb-toggle-hover-accent-color:#ca1517;--awb-title-font-family:&quot;Raleway&quot;;--awb-title-font-weight:400;--awb-title-font-style:normal;--awb-title-font-size:16px;--awb-content-font-family:&quot;Raleway&quot;;--awb-content-font-style:normal;--awb-content-font-weight:regular;\"><div class=\"panel-group fusion-toggle-icon-boxed\" id=\"accordion-427-1\"><div class=\"fusion-panel panel-default panel-585d0be999e0c8278 fusion-toggle-has-divider\"><div class=\"panel-heading\"><h4 class=\"panel-title toggle\" id=\"toggle_585d0be999e0c8278\"><a aria-expanded=\"false\" aria-controls=\"585d0be999e0c8278\" role=\"button\" data-toggle=\"collapse\" data-parent=\"#accordion-427-1\" data-target=\"#585d0be999e0c8278\" href=\"#585d0be999e0c8278\"><span class=\"fusion-toggle-icon-wrapper\" aria-hidden=\"true\"><i class=\"fa-fusion-box active-icon awb-icon-minus\" aria-hidden=\"true\"><\/i><i class=\"fa-fusion-box inactive-icon awb-icon-plus\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-toggle-heading\">BOOK A HOME VISIT OR ONLINE SERVICE<\/span><\/a><\/h4><\/div><div id=\"585d0be999e0c8278\" class=\"panel-collapse collapse \" aria-labelledby=\"toggle_585d0be999e0c8278\"><div class=\"panel-body toggle-content fusion-clearfix\"><script>\nvar 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class='gfield_description' id='gfield_description_6_126'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_6_97\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_6_97'>Submission Date time<\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_6_97' type='text' value='06\/06\/2026\\ \\am\\30\\ 04:52:33' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_102\" class=\"gfield gfield--type-uid gfield--input-type-uid gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><label class='gfield_label gform-field-label' for='input_6_102'>CASE NUMBER<\/label><div class='ginput_container ginput_container_hidden'><input name='input_102' id='input_6_102' type='hidden' value=''  \/><\/div><\/div><div id=\"field_6_103\" class=\"gfield gfield--type-uid gfield--input-type-uid gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><label class='gfield_label gform-field-label' for='input_6_103'>BOOKING ID<\/label><div class='ginput_container ginput_container_hidden'><input name='input_103' id='input_6_103' type='hidden' value=''  \/><\/div><\/div><div id=\"field_6_34\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"form-title\">Some fields are mandatory so as to assist you and invoice the service we will provide (*) <\/h3><\/div><fieldset id=\"field_6_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >I have already received information on service fees for my area and I want to proceed with a booking.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_47'>\n\t\t\t<div class='gchoice gchoice_6_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Yes'  id='choice_6_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_47_0' id='label_6_47_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='No'  id='choice_6_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_47_1' id='label_6_47_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_50\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"form-title\">This is a booking form. Please contact us by chat, phone or through our   <a href=\"https:\/\/www.medelit.com\/uk\/contact-us\/\">info request form<\/a> to receive information regarding cover of service and fees for your area <\/h3><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_6_119' 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_6_2' class='gform_page' data-js='page-field-id-119' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_6_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >I am<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_45'>\n\t\t\t<div class='gchoice gchoice_6_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='A New patient'  id='choice_6_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_45_0' id='label_6_45_0' class='gform-field-label gform-field-label--type-inline'>A New patient<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='A returning patient'  id='choice_6_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_45_1' id='label_6_45_1' class='gform-field-label gform-field-label--type-inline'>A returning patient<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_46\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_6_46'>Please complete with this field with the PATIENT'S FULL Name and Surname ONLY - do not complete with anyone else's information.<\/div><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_6_46'>\n                            <span id='input_6_46_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_46.2' id='input_6_46_2'    aria-required='false'   >\n                          <option value=''><\/option><option value='Dr' >Dr<\/option><option value='Miss' >Miss<\/option><option value='Mr' >Mr<\/option><option value='Mrs' >Mrs<\/option><option value='Ms' >Ms<\/option><option value='Prof' >Prof<\/option><option value='Rev' >Rev<\/option>\n                      <\/select>\n                                                    <label for='input_6_46_2' class='gform-field-label gform-field-label--type-sub '>Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_6_46_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_46.3' id='input_6_46_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_46_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_6_46_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_46.4' id='input_6_46_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_46_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_6_46_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_46.6' id='input_6_46_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_46_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_39\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_39'>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_39' id='input_6_39' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_6_39_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_39_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_39' class='gform_hidden' value='https:\/\/www.medelit.com\/uk\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_4\" class=\"gfield gfield--type-email gfield--input-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_6_4'>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_4' id='input_6_4' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_6_6\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_6'>Telephone for Contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_6_6' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_107\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_6_107'>RET PT ID<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_6_107' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_32\" class=\"gfield gfield--type-phone gfield--input-type-phone 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' for='input_6_32'>Telephone 2<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_6_32'>Please leave us 2 phone numbers if possible<\/div><div class='ginput_container ginput_container_phone'><input name='input_32' id='input_6_32' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_6_32\"  \/><\/div><\/div><div id=\"field_6_114\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Sorry, we can't seem to find you in our systems. Please double-check that the information you provided is correct and corresponds to the information you provided at initial registration.<\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_62' 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_6_62' 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_6_3' class='gform_page' data-js='page-field-id-62' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_105\" class=\"gfield gfield--type-uid gfield--input-type-uid gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><label class='gfield_label gform-field-label' for='input_6_105'>PATIENT ID<\/label><div class='ginput_container ginput_container_hidden'><input name='input_105' id='input_6_105' type='hidden' value=''  \/><\/div><\/div><div id=\"field_6_117\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Welcome back! \nPlease select the Service You require<\/div><fieldset id=\"field_6_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Type of Service Needed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_78'>\n\t\t\t<div class='gchoice gchoice_6_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='REMOTE'  id='choice_6_78_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_78_0' id='label_6_78_0' class='gform-field-label gform-field-label--type-inline'>REMOTE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='HOME VISIT'  id='choice_6_78_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_78_1' id='label_6_78_1' class='gform-field-label gform-field-label--type-inline'>HOME VISIT<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_20\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What Home Visit are You Booking?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_20'><div class='gchoice gchoice_6_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='MEDICAL'  id='choice_6_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_20_1' id='label_6_20_1' class='gform-field-label gform-field-label--type-inline'>MEDICAL<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='ALTERNATIVE MEDICINE'  id='choice_6_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_20_2' id='label_6_20_2' class='gform-field-label gform-field-label--type-inline'>ALTERNATIVE MEDICINE<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='NURSING CARE'  id='choice_6_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_20_3' id='label_6_20_3' class='gform-field-label gform-field-label--type-inline'>NURSING CARE<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='NUTRITIONAL THERAPY'  id='choice_6_20_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_20_4' id='label_6_20_4' class='gform-field-label gform-field-label--type-inline'>NUTRITIONAL THERAPY<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_20_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.5' type='checkbox'  value='PHYSIOTHERAPY'  id='choice_6_20_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_20_5' id='label_6_20_5' class='gform-field-label gform-field-label--type-inline'>PHYSIOTHERAPY<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_20_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.6' type='checkbox'  value='PODIATRY'  id='choice_6_20_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_20_6' id='label_6_20_6' class='gform-field-label gform-field-label--type-inline'>PODIATRY<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_20_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.7' type='checkbox'  value='PSYCHOLOGY'  id='choice_6_20_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_20_7' id='label_6_20_7' class='gform-field-label gform-field-label--type-inline'>PSYCHOLOGY<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_20_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.8' type='checkbox'  value='SPEECH THERAPY'  id='choice_6_20_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_20_8' id='label_6_20_8' class='gform-field-label gform-field-label--type-inline'>SPEECH THERAPY<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_94\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_94'>What Medical Service are you Booking?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_94' id='input_6_94' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='GENERAL PRACTICE' >GENERAL PRACTICE<\/option><option value='FUNCTIONAL MEDICINE' >FUNCTIONAL MEDICINE<\/option><option value='GERIATRICS' >GERIATRICS<\/option><option value='GYNAECOLOGY' >GYNAECOLOGY<\/option><option value='ORTHOPAEDICS' >ORTHOPAEDICS<\/option><option value='PHYSICAL MEDICINE &amp; REHABILITATION' >PHYSICAL MEDICINE &amp; REHABILITATION<\/option><option value='PSYCHIATRY' >PSYCHIATRY<\/option><\/select><\/div><\/div><fieldset id=\"field_6_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Which Alternative Medicine Service do You need?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_81'>\n\t\t\t<div class='gchoice gchoice_6_81_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='ACUPUNCTURE'  id='choice_6_81_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_81_0' id='label_6_81_0' class='gform-field-label gform-field-label--type-inline'>ACUPUNCTURE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_81_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='OTHER'  id='choice_6_81_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_81_1' id='label_6_81_1' class='gform-field-label gform-field-label--type-inline'>OTHER<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_82\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Which Nursing Service do you need?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_82'>\n\t\t\t<div class='gchoice gchoice_6_82_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='BLOOD &amp; COVID TESTS'  id='choice_6_82_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_82_0' id='label_6_82_0' class='gform-field-label gform-field-label--type-inline'>BLOOD &amp; COVID TESTS<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_82_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='BOWEL CARE'  id='choice_6_82_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_82_1' id='label_6_82_1' class='gform-field-label gform-field-label--type-inline'>BOWEL CARE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_82_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='MEDICINE &amp; IV ADMINISTRATION'  id='choice_6_82_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_82_2' id='label_6_82_2' class='gform-field-label gform-field-label--type-inline'>MEDICINE &amp; IV ADMINISTRATION<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_82_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='ON-DEMAN NURSE'  id='choice_6_82_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_82_3' id='label_6_82_3' class='gform-field-label gform-field-label--type-inline'>ON-DEMAN NURSE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_82_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='STOMA CARE'  id='choice_6_82_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_82_4' id='label_6_82_4' class='gform-field-label gform-field-label--type-inline'>STOMA CARE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_82_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='URINARY CATHETER CARE'  id='choice_6_82_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_82_5' id='label_6_82_5' class='gform-field-label gform-field-label--type-inline'>URINARY CATHETER CARE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_82_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='VENOUS CATHETERS'  id='choice_6_82_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_82_6' id='label_6_82_6' class='gform-field-label gform-field-label--type-inline'>VENOUS CATHETERS<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_82_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='WOUND CARE &amp; DRESSING'  id='choice_6_82_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_82_7' id='label_6_82_7' class='gform-field-label gform-field-label--type-inline'>WOUND CARE &amp; DRESSING<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_83\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Which Physiotherapy Service are you booking?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_83'>\n\t\t\t<div class='gchoice gchoice_6_83_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='PHYSIOTHERAPY'  id='choice_6_83_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_83_0' id='label_6_83_0' class='gform-field-label gform-field-label--type-inline'>PHYSIOTHERAPY<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_83_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='NEUROPHYSIOTHERAPY'  id='choice_6_83_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_83_1' id='label_6_83_1' class='gform-field-label gform-field-label--type-inline'>NEUROPHYSIOTHERAPY<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_83_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='RESPIRATORY PHYSIOTHERAPY'  id='choice_6_83_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_83_2' id='label_6_83_2' class='gform-field-label gform-field-label--type-inline'>RESPIRATORY PHYSIOTHERAPY<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_84\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Which Speech and Language Service are you booking?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_84'>\n\t\t\t<div class='gchoice gchoice_6_84_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='ADULT SPEECH &amp; LANGUAGE THERAPY'  id='choice_6_84_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_84_0' id='label_6_84_0' class='gform-field-label gform-field-label--type-inline'>ADULT SPEECH &amp; LANGUAGE THERAPY<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_84_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='CHILD SPEECH &amp; LANGUAGE THERAPY'  id='choice_6_84_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_84_1' id='label_6_84_1' class='gform-field-label gform-field-label--type-inline'>CHILD SPEECH &amp; LANGUAGE THERAPY<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_95\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_95'>What Online Service are you booking?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_95' id='input_6_95' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='MEDICAL' >MEDICAL<\/option><option value='PHYSIOTHERAPY' >PHYSIOTHERAPY<\/option><option value='NUTRITIONAL THERAPY' >NUTRITIONAL THERAPY<\/option><option value='PSYCHOLOGY' >PSYCHOLOGY<\/option><option value='SPEECH THERAPY' >SPEECH THERAPY<\/option><\/select><\/div><\/div><div id=\"field_6_101\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_6_101'>SERVICE CATEGORY<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_6_101' type='text' data-gppa-live-merge-tag-value=\"@{:95} @{:94}\" value=' ' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_96\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_96'>What Medical Video Consultation are you Booking?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_96' id='input_6_96' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='GENERAL PRACTICE' >GENERAL PRACTICE<\/option><option value='FUNCTIONAL MEDICINE' >FUNCTIONAL MEDICINE<\/option><option value='GERIATRICS' >GERIATRICS<\/option><option value='GYNAECOLOGY' >GYNAECOLOGY<\/option><option value='ORTHOPAEDICS' >ORTHOPAEDICS<\/option><option value='PHYSICAL MEDICINE &amp; REHABILITATION' >PHYSICAL MEDICINE &amp; REHABILITATION<\/option><option value='PSYCHIATRY' >PSYCHIATRY<\/option><\/select><\/div><\/div><fieldset id=\"field_6_88\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Which Online Speech and Language Service are you booking?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_88'>\n\t\t\t<div class='gchoice gchoice_6_88_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='ADULT SPEECH &amp; LANGUAGE THERAPY'  id='choice_6_88_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_88_0' id='label_6_88_0' class='gform-field-label gform-field-label--type-inline'>ADULT SPEECH &amp; LANGUAGE THERAPY<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_88_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='CHILD SPEECH &amp; LANGUAGE THERAPY'  id='choice_6_88_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_88_1' id='label_6_88_1' class='gform-field-label gform-field-label--type-inline'>CHILD SPEECH &amp; LANGUAGE THERAPY<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_99\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_6_99'>Service selected<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_6_99' type='text' value=\"\" data-gppa-live-merge-tag-value=\"@{:88}@{:96}@{:81}@{:82}@{:83}@{:84}@{:94}\" class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_79' 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_6_79' 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_6_4' class='gform_page' data-js='page-field-id-79' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_104\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_104'>Is this visit at the same address we have on record?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_104' id='input_6_104' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='YES' >YES<\/option><option value='NO' >NO<\/option><option value='NOT SURE' >NOT SURE<\/option><\/select><\/div><\/div><div id=\"field_6_110\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_110'>RET-PT PT ADDRESS<\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_6_110' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_112\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_6_112'>RET-PT Address Details<\/label><div class='ginput_container ginput_container_text'><input name='input_112' id='input_6_112' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_56\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >NEW Visit Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip has_country ginput_container_address gform-grid-row' id='input_6_56' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_56_1_container' >\n                                        <input type='text' name='input_56.1' id='input_6_56_1' value=''    aria-required='true'    \/>\n                                        <label for='input_6_56_1' id='input_6_56_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_6_56_3_container' >\n                                    <input type='text' name='input_56.3' id='input_6_56_3' value=''    aria-required='true'    \/>\n                                    <label for='input_6_56_3' id='input_6_56_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_56.4' id='input_6_56_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_6_56_5_container' >\n                                    <input type='text' name='input_56.5' id='input_6_56_5' value=''    aria-required='true'    \/>\n                                    <label for='input_6_56_5' id='input_6_56_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_6_56_6_container' >\n                                        <select name='input_56.6' id='input_6_56_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' >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' selected='selected'>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_6_56_6' id='input_6_56_6_label' class='gform-field-label gform-field-label--type-sub '>United Kingdom<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><input type=\"hidden\" name=\"gpaa_place_56\" class=\"gform_hidden\" value=\"\"><\/fieldset><fieldset id=\"field_6_118\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Visit Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip has_country ginput_container_address gform-grid-row' id='input_6_118' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_118_1_container' >\n                                        <input type='text' name='input_118.1' id='input_6_118_1' value=''    aria-required='true'    \/>\n                                        <label for='input_6_118_1' id='input_6_118_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_6_118_3_container' >\n                                    <input type='text' name='input_118.3' id='input_6_118_3' value=''    aria-required='true'    \/>\n                                    <label for='input_6_118_3' id='input_6_118_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_118.4' id='input_6_118_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_6_118_5_container' >\n                                    <input type='text' name='input_118.5' id='input_6_118_5' value=''    aria-required='true'    \/>\n                                    <label for='input_6_118_5' id='input_6_118_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_6_118_6_container' >\n                                        <select name='input_118.6' id='input_6_118_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' >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' selected='selected'>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_6_118_6' id='input_6_118_6_label' class='gform-field-label gform-field-label--type-sub '>United Kingdom<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><input type=\"hidden\" name=\"gpaa_place_118\" class=\"gform_hidden\" value=\"\"><\/fieldset><div id=\"field_6_12\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_12'>Street Level Intercom<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_6_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_120\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_120'>New Address Street Level Intercom<\/label><div class='ginput_container ginput_container_text'><input name='input_120' id='input_6_120' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_57\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_57'>Floor<\/label><div class='ginput_container ginput_container_number'><input name='input_57' id='input_6_57' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_121\" class=\"gfield gfield--type-number gfield--input-type-number 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_6_121'>New Address Floor<\/label><div class='ginput_container ginput_container_number'><input name='input_121' id='input_6_121' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_13\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_13'>Apt\/Staircase<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_6_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_122\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_122'>New Address Apt\/Staircase<\/label><div class='ginput_container ginput_container_text'><input name='input_122' id='input_6_122' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_77' 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_6_77' 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_6_5' class='gform_page' data-js='page-field-id-77' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_6_44\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Invoicing Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip has_country ginput_container_address gform-grid-row' id='input_6_44' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_44_1_container' >\n                                        <input type='text' name='input_44.1' id='input_6_44_1' value=''    aria-required='true'    \/>\n                                        <label for='input_6_44_1' id='input_6_44_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_44_3_container' >\n                                    <input type='text' name='input_44.3' id='input_6_44_3' value=''    aria-required='true'    \/>\n                                    <label for='input_6_44_3' id='input_6_44_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_44.4' id='input_6_44_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_6_44_5_container' >\n                                    <input type='text' name='input_44.5' id='input_6_44_5' value=''    aria-required='true'    \/>\n                                    <label for='input_6_44_5' id='input_6_44_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_6_44_6_container' >\n                                        <select name='input_44.6' id='input_6_44_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' >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' selected='selected'>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_6_44_6' id='input_6_44_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><input type=\"hidden\" name=\"gpaa_place_44\" class=\"gform_hidden\" value=\"\"><\/fieldset><div id=\"field_6_40\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"form-title\">Invoice Information<\/h3><\/div><div id=\"field_6_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_43'>Country of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_6_43' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_64' 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_6_64' 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_6_6' class='gform_page' data-js='page-field-id-64' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_42\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"form-title\">BOOKING INFORMATION <\/h3><\/div><div id=\"field_6_17\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_6_17'>Please provide details on the reason for your visit<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_6_17' class='textarea small'  aria-describedby=\"gfield_description_6_17\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_6_17'>This information is very important as it will allow us to ensure you are matched with the best healthcare professional and that they are well informed of the situation prior to the visit.\nIf you are requesting a BLOOD TEST please take notice you will need to add the blood test CODE\/S in this field.<\/div><\/div><div id=\"field_6_89\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_89'>Please let us know whether you have any preferences in terms of date and time for the visit.*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_89' id='input_6_89' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='ASAP' >ASAP<\/option><option value='ASAP but NOT on these days or time' >ASAP but NOT on these days or time<\/option><option value='SCHEDULE SPECIFIC DAY\/TIME' >SCHEDULE SPECIFIC DAY\/TIME<\/option><\/select><\/div><\/div><div id=\"field_6_90\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_90'>Please add the Date you are NOT AVAILABLE for the visit<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_90' id='input_6_90' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_6_90_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_90_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_90' class='gform_hidden' value='https:\/\/www.medelit.com\/uk\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_91\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_91'>Is there any specific time visit CANNOT work for you on this date?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_91' id='input_6_91' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='NOT Available the WHOLE DAY' >NOT Available the WHOLE DAY<\/option><option value='NOT in the Morning - 08:00-12:00' >NOT in the Morning - 08:00-12:00<\/option><option value='NOT in the Afternoon - 12:00-20:00' >NOT in the Afternoon - 12:00-20:00<\/option><\/select><\/div><\/div><div id=\"field_6_92\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_92'>Please, Select a date you&#039;d prefer to have the service<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_92' id='input_6_92' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_6_92_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_92_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_92' class='gform_hidden' value='https:\/\/www.medelit.com\/uk\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_93\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_93'>Any preference of time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_93' id='input_6_93' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='MORNING - 08:00-12:00' >MORNING - 08:00-12:00<\/option><option value='AFTERNOON - 12:00-20:00' >AFTERNOON - 12:00-20:00<\/option><\/select><\/div><\/div><div id=\"field_6_100\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_6_100'>PREFERRED TIME<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_6_100' type='text' data-gppa-live-merge-tag-value=\"@{:89} @{:91} @{:90} @{:92} @{:93}\" value='    ' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_29\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How did you find us ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_29'><div class='gchoice gchoice_6_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='GP\/Other Doctor'  id='choice_6_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_29_1' id='label_6_29_1' class='gform-field-label gform-field-label--type-inline'>GP\/Other Doctor<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='Family\/Friends'  id='choice_6_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_29_2' id='label_6_29_2' class='gform-field-label gform-field-label--type-inline'>Family\/Friends<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_29_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.3' type='checkbox'  value='Hospital\/Clinic'  id='choice_6_29_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_29_3' id='label_6_29_3' class='gform-field-label gform-field-label--type-inline'>Hospital\/Clinic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_29_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.4' type='checkbox'  value='NHS'  id='choice_6_29_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_29_4' id='label_6_29_4' class='gform-field-label gform-field-label--type-inline'>NHS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_29_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.5' type='checkbox'  value='Internet'  id='choice_6_29_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_29_5' id='label_6_29_5' class='gform-field-label gform-field-label--type-inline'>Internet<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_29_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.6' type='checkbox'  value='Leaflet'  id='choice_6_29_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_29_6' id='label_6_29_6' class='gform-field-label gform-field-label--type-inline'>Leaflet<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_29_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.7' type='checkbox'  value='Insurance'  id='choice_6_29_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_29_7' id='label_6_29_7' class='gform-field-label gform-field-label--type-inline'>Insurance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_29_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.8' type='checkbox'  value='Adds'  id='choice_6_29_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_29_8' id='label_6_29_8' class='gform-field-label gform-field-label--type-inline'>Adds<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_58\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_6_58'>Upload your Prescription\/Doctor&#039;s Referral Letter<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_6_58'>The service you are booking requires a referral letter or prescription. Please upload your document here.<\/div><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_6_58' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_6_58&quot;,&quot;container&quot;:&quot;gform_multifile_upload_6_58&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_6_58&quot;,&quot;filelist&quot;:&quot;gform_preview_6_58&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.medelit.com\\\/uk\\\/?gf_page=00814780d828b50&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.medelit.com\\\/uk\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.medelit.com\\\/uk\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;35840000b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:6,&quot;field_id&quot;:58,&quot;_gform_file_upload_nonce_6_58&quot;:&quot;019acd9ff5&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_6_58&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_6_58' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_6_58' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_6_58 gfield_description_6_58\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_6_58'>Max. file size: 34 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_6_58'><\/ul> <div id='gform_preview_6_58' class='ginput_preview_list'><\/div><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_65' 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_6_65' 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_6_7' class='gform_page' data-js='page-field-id-65' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_66\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"form-title\">We're nearly done! Now to CONSENT AND PRIVACY<\/h3><\/div><fieldset id=\"field_6_68\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you filling this form for yourself?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_68'>\n\t\t\t<div class='gchoice gchoice_6_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Yes'  id='choice_6_68_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_68_0' id='label_6_68_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='No'  id='choice_6_68_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_68_1' id='label_6_68_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_69\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have consent to book this visit and share the patient&#039;s information with us?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_69'>\n\t\t\t<div class='gchoice gchoice_6_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Yes'  id='choice_6_69_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_6_69\"   \/>\n\t\t\t\t\t<label for='choice_6_69_0' id='label_6_69_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='No, but I have Power of Attorney'  id='choice_6_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_69_1' id='label_6_69_1' class='gform-field-label gform-field-label--type-inline'>No, but I have Power of Attorney<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_6_69'>Please take notice that if you are NOT the person we are visiting and you do not have their consent, you can provide consent ONLY if you have Power of Attorney. The Power of Attorney Documentation will need to be uploaded within this form.<\/div><\/fieldset><fieldset id=\"field_6_70\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_6_70'>\n                            \n                            <span id='input_6_70_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_70.3' id='input_6_70_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_70_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_70_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_70.6' id='input_6_70_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_70_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_6_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you been Appointed Power of Attorney?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_71'>\n\t\t\t<div class='gchoice gchoice_6_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Yes'  id='choice_6_71_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_6_71\"   \/>\n\t\t\t\t\t<label for='choice_6_71_0' id='label_6_71_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='No'  id='choice_6_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_71_1' id='label_6_71_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_6_71'>Please take notice this is for Health and Welfare as well as for property and financial affairs.\nPlease take notice that if the person we are visiting is NOT a child under the age of 18 for whom you have parental responsibility, you can only provide consent if you have been appointed Power of Attorney.\nIf your answer is NO, this means you do not ahave a right to give consent. Please take notice that we cannot process your booking without the patient's consent to the treatment of their data.<\/div><\/fieldset><div id=\"field_6_125\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_125'>Upload the POA document<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='35840000' \/><input name='input_125' id='input_6_125' type='file' class='large' aria-describedby=\"gfield_upload_rules_6_125\" onchange='javascript:gformValidateFileSize( this, 35840000 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_6_125'>Max. file size: 34 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_6_125'><\/div> <\/div><\/div><div id=\"field_6_73\" class=\"gfield gfield--type-signature gfield--input-type-signature field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_73'>Signature<\/label><input type='hidden' value='' name='input_73' id='input_6_73_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_6_73_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_6_73' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/www.medelit.com\/uk\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_6_73_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_6_73_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_6_73_data' name='input_6_73_data' value=''><\/div><\/div><div id=\"field_6_76\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_76'>Do You have a Discount Code? Send it here!<\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_6_76' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_124\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible image-choices-field image-choices-use-images image-choices-show-labels ic-theme--simple ic-cols--fixed ic-cols-md--fixed ic-cols-sm--fixed ic-lightbox-captions \"  data-field-class=\"image-choices-field image-choices-use-images image-choices-show-labels ic-theme--simple ic-cols--fixed ic-cols-md--fixed ic-cols-sm--fixed ic-lightbox-captions\" ><label class='gfield_label gform-field-label' for='input_6_124'>How do you prefer to pay your Booking?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_124' id='input_6_124' class='large gfield_select'  aria-describedby=\"gfield_description_6_124\"  aria-required=\"true\" aria-invalid=\"false\" ><option data-image-src=\"https:\/\/www.medelit.com\/uk\/wp-content\/uploads\/sites\/3\/2024\/10\/credit-card-security.png\" value='CREDIT\/DEBIT CARD' >CREDIT\/DEBIT CARD<\/option><option data-image-src=\"https:\/\/www.medelit.com\/uk\/wp-content\/uploads\/sites\/3\/2024\/10\/paypal.png\" value='PAYPAL' >PAYPAL<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_6_124'>No payment is required now. You will receive an appointment proposal w<\/div><\/div><fieldset id=\"field_6_30\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_30.1' id='input_6_30_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_6_30\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_30_1' >Acceptance of terms<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_30.2' value='Acceptance of terms' class='gform_hidden' \/><input type='hidden' name='input_30.3' value='10' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_6_30' tabindex='0'>By selecting you are confirming that you have read and accepted our booking terms & conditions and that you are providing consent to the visit and our privacy policy in regards to treatment of your data.<br \/>\nThe privacy policy can be accessed through this link: https:\/\/www.medelit.com\/uk\/data-protection-policy\/<\/div><\/fieldset><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_6' 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='submit' id='gform_submit_button_6' class='gform_button button' 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@{:93}\":\"\",\"@{:88}@{:96}@{:81}@{:82}@{:83}@{:84}@{:94}\":\"\"};\n\t\t\t<\/script><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container hundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-separator fusion-full-width-sep\" style=\"align-self: center;margin-left: auto;margin-right: auto;width:100%;\"><div class=\"fusion-separator-border sep-shadow\" style=\"--awb-height:20px;--awb-amount:20px;--awb-sep-color:#ca1517;background:radial-gradient(ellipse at 50% -50% , #ca1517 0px, rgba(255, 255, 255, 0) 80%) repeat scroll 0 0 rgba(0, 0, 0, 0);background:-webkit-radial-gradient(ellipse at 50% -50% , #ca1517 0px, rgba(255, 255, 255, 0) 80%) repeat scroll 0 0 rgba(0, 0, 0, 0);background:-moz-radial-gradient(ellipse at 50% -50% , #ca1517 0px, rgba(255, 255, 255, 0) 80%) repeat scroll 0 0 rgba(0, 0, 0, 0);background:-o-radial-gradient(ellipse at 50% -50% , #ca1517 0px, rgba(255, 255, 255, 0) 80%) repeat scroll 0 0 rgba(0, 0, 0, 0);\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-3 fusion-flex-container hundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:60px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-4\"><p><strong>Not sure on whether we cover your area and need information on our clinicians&#8217; fees?<\/strong> Contact us, and we will get back to you with a quick response:<\/p>\n<\/div><div class=\"accordian fusion-accordian\" style=\"--awb-border-size:1px;--awb-icon-size:13px;--awb-content-font-size:16px;--awb-icon-alignment:left;--awb-hover-color:#f9f9f9;--awb-border-color:#cccccc;--awb-background-color:#ffffff;--awb-divider-color:#e0dede;--awb-divider-hover-color:#e0dede;--awb-icon-color:#ffffff;--awb-title-color:#ca1517;--awb-content-color:#000000;--awb-icon-box-color:#333333;--awb-toggle-hover-accent-color:#ca1517;--awb-title-font-family:&quot;Raleway&quot;;--awb-title-font-weight:400;--awb-title-font-style:normal;--awb-title-font-size:16px;--awb-content-font-family:&quot;Raleway&quot;;--awb-content-font-style:normal;--awb-content-font-weight:regular;\"><div class=\"panel-group fusion-toggle-icon-boxed\" id=\"accordion-427-2\"><div class=\"fusion-panel panel-default panel-ad3b1d29dcb65a178 fusion-toggle-has-divider\"><div class=\"panel-heading\"><h4 class=\"panel-title toggle\" id=\"toggle_ad3b1d29dcb65a178\"><a aria-expanded=\"false\" aria-controls=\"ad3b1d29dcb65a178\" role=\"button\" data-toggle=\"collapse\" data-parent=\"#accordion-427-2\" data-target=\"#ad3b1d29dcb65a178\" href=\"#ad3b1d29dcb65a178\"><span class=\"fusion-toggle-icon-wrapper\" aria-hidden=\"true\"><i class=\"fa-fusion-box active-icon awb-icon-minus\" aria-hidden=\"true\"><\/i><i class=\"fa-fusion-box inactive-icon awb-icon-plus\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-toggle-heading\">QUICK INFO REQUEST<\/span><\/a><\/h4><\/div><div id=\"ad3b1d29dcb65a178\" class=\"panel-collapse collapse \" aria-labelledby=\"toggle_ad3b1d29dcb65a178\"><div class=\"panel-body toggle-content fusion-clearfix\">\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_3' style='display:none'><style>#gform_wrapper_3[data-form-index=\"0\"].gform-theme,[data-parent-form=\"3_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: 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var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Contact Us<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/uk\/wp-json\/wp\/v2\/pages\/427#gf_3' data-formid='3' novalidate><input type=\"hidden\" name=\"gpuid_existing_value_15\" id=\"gpuid_existing_value_15\" value=\"7e3e2dc7086e13f14d146a36118ef35a\" \/>\n        <div id='gf_progressbar_wrapper_3' 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'>3<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_33' style='width:33%;'><span>33%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_3_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_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_18\" 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_3_18'>Phone<\/label><div class='ginput_container'><input name='input_18' id='input_3_18' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_3_18'>This field is for validation purposes and should be left unchanged.<\/div><\/li><li id=\"field_3_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_3_10'>\n\t\t\t<li class='gchoice gchoice_3_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='NEW Patient'  id='choice_3_10_0'    \/>\n\t\t\t\t<label for='choice_3_10_0' id='label_3_10_0' class='gform-field-label gform-field-label--type-inline'>NEW Patient<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='RETURNING Patient'  id='choice_3_10_1'    \/>\n\t\t\t\t<label for='choice_3_10_1' id='label_3_10_1' class='gform-field-label gform-field-label--type-inline'>RETURNING Patient<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_3_1'>\n                            <span id='input_3_1_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_1.2' id='input_3_1_2'    aria-required='false'   >\n                          <option value=''><\/option><option value='Mr' >Mr<\/option><option value='Mrs' >Mrs<\/option><option value='Miss' >Miss<\/option><option value='Ms' >Ms<\/option><option value='Dr' >Dr<\/option><option value='Prof' >Prof<\/option><option value='Rev' >Rev<\/option>\n                      <\/select>\n                                                    <label for='input_3_1_2' class='gform-field-label gform-field-label--type-sub '>Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_3_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_3_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_3_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_3_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Type of Service I am enquiring about:<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_3_11'>\n\t\t\t<li class='gchoice gchoice_3_11_0'>\n\t\t\t\t<input name='input_11' type='radio' value='HOME VISIT'  id='choice_3_11_0'    \/>\n\t\t\t\t<label for='choice_3_11_0' id='label_3_11_0' class='gform-field-label gform-field-label--type-inline'>HOME VISIT<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_11_1'>\n\t\t\t\t<input name='input_11' type='radio' value='ONLINE'  id='choice_3_11_1'    \/>\n\t\t\t\t<label for='choice_3_11_1' id='label_3_11_1' class='gform-field-label gform-field-label--type-inline'>ONLINE<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_11_2'>\n\t\t\t\t<input name='input_11' type='radio' value='CORPORATE SERVICE'  id='choice_3_11_2'    \/>\n\t\t\t\t<label for='choice_3_11_2' id='label_3_11_2' class='gform-field-label gform-field-label--type-inline'>CORPORATE SERVICE<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >VIDEO Consultation - I am interested in:<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_3_12'>\n\t\t\t<li class='gchoice gchoice_3_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='General Practice\/Primary Care'  id='choice_3_12_0'    \/>\n\t\t\t\t<label for='choice_3_12_0' id='label_3_12_0' class='gform-field-label gform-field-label--type-inline'>General Practice\/Primary Care<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_12_1'>\n\t\t\t\t<input name='input_12' type='radio' value='Specialistic Medicine'  id='choice_3_12_1'    \/>\n\t\t\t\t<label for='choice_3_12_1' id='label_3_12_1' class='gform-field-label gform-field-label--type-inline'>Specialistic Medicine<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_12_2'>\n\t\t\t\t<input name='input_12' type='radio' value='Speech Therapy'  id='choice_3_12_2'    \/>\n\t\t\t\t<label for='choice_3_12_2' id='label_3_12_2' class='gform-field-label gform-field-label--type-inline'>Speech Therapy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_12_3'>\n\t\t\t\t<input name='input_12' type='radio' value='Psychology'  id='choice_3_12_3'    \/>\n\t\t\t\t<label for='choice_3_12_3' id='label_3_12_3' class='gform-field-label gform-field-label--type-inline'>Psychology<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_12_4'>\n\t\t\t\t<input name='input_12' type='radio' value='Physiotherapy'  id='choice_3_12_4'    \/>\n\t\t\t\t<label for='choice_3_12_4' id='label_3_12_4' class='gform-field-label gform-field-label--type-inline'>Physiotherapy<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >HOME Visit - I am interested in:<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_3_13'>\n\t\t\t<li class='gchoice gchoice_3_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='General Practice\/Primary Care'  id='choice_3_13_0'    \/>\n\t\t\t\t<label for='choice_3_13_0' id='label_3_13_0' class='gform-field-label gform-field-label--type-inline'>General Practice\/Primary Care<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='Specialistic Medicine'  id='choice_3_13_1'    \/>\n\t\t\t\t<label for='choice_3_13_1' id='label_3_13_1' class='gform-field-label gform-field-label--type-inline'>Specialistic Medicine<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_13_2'>\n\t\t\t\t<input name='input_13' type='radio' value='ACUPUNCTURE'  id='choice_3_13_2'    \/>\n\t\t\t\t<label for='choice_3_13_2' id='label_3_13_2' class='gform-field-label gform-field-label--type-inline'>ACUPUNCTURE<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_13_3'>\n\t\t\t\t<input name='input_13' type='radio' value='NURSES'  id='choice_3_13_3'    \/>\n\t\t\t\t<label for='choice_3_13_3' id='label_3_13_3' class='gform-field-label gform-field-label--type-inline'>NURSES<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_13_4'>\n\t\t\t\t<input name='input_13' type='radio' value='NUTRITIONAL THERAPY'  id='choice_3_13_4'    \/>\n\t\t\t\t<label for='choice_3_13_4' id='label_3_13_4' class='gform-field-label gform-field-label--type-inline'>NUTRITIONAL THERAPY<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_13_5'>\n\t\t\t\t<input name='input_13' type='radio' value='PHYSIOTHERAPY'  id='choice_3_13_5'    \/>\n\t\t\t\t<label for='choice_3_13_5' id='label_3_13_5' class='gform-field-label gform-field-label--type-inline'>PHYSIOTHERAPY<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_13_6'>\n\t\t\t\t<input name='input_13' type='radio' value='PSYCHOLOGY'  id='choice_3_13_6'    \/>\n\t\t\t\t<label for='choice_3_13_6' id='label_3_13_6' class='gform-field-label gform-field-label--type-inline'>PSYCHOLOGY<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_13_7'>\n\t\t\t\t<input name='input_13' type='radio' value='PODIATRY'  id='choice_3_13_7'    \/>\n\t\t\t\t<label for='choice_3_13_7' id='label_3_13_7' class='gform-field-label gform-field-label--type-inline'>PODIATRY<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_13_8'>\n\t\t\t\t<input name='input_13' type='radio' value='SPEECH THERAPY'  id='choice_3_13_8'    \/>\n\t\t\t\t<label for='choice_3_13_8' id='label_3_13_8' class='gform-field-label gform-field-label--type-inline'>SPEECH THERAPY<\/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_next_button_3_16' 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_3_2' class='gform_page' data-js='page-field-id-16' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_2\" class=\"gfield gfield--type-email gfield--input-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_3_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_3_2' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_3_3\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_3_3'>Telephone<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_3_3' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_5\" class=\"gfield gfield--type-address gfield--input-type-address 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 gfield_label_before_complex' >VISIT Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_3_5'>Please take notice that you are contacting Medelit UK. Our home care services are active in the UK ONLY.<\/div>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip has_country ginput_container_address gform-grid-row' id='input_3_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_3_5_1' value=''    aria-required='true'    \/>\n                                        <label for='input_3_5_1' id='input_3_5_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_3_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_3_5_3' value=''    aria-required='true'    \/>\n                                    <label for='input_3_5_3' id='input_3_5_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_5.4' id='input_3_5_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_3_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_3_5_5' value=''    aria-required='true'    \/>\n                                    <label for='input_3_5_5' id='input_3_5_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_3_5_6_container' >\n                                        <select name='input_5.6' id='input_3_5_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' >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' selected='selected'>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_3_5_6' id='input_3_5_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><input type=\"hidden\" name=\"gpaa_place_5\" class=\"gform_hidden\" value=\"\"><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_17' 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_3_17' 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_3_3' class='gform_page' data-js='page-field-id-17' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_7\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_7'>Your Message<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_7' id='input_3_7' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_3_8\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >How did you find Medelit?<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_3_8'><li class='gchoice gchoice_3_8_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.1' type='checkbox'  value='Internet'  id='choice_3_8_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_1' id='label_3_8_1' class='gform-field-label gform-field-label--type-inline'>Internet<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_8_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.2' type='checkbox'  value='GP'  id='choice_3_8_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_2' id='label_3_8_2' class='gform-field-label gform-field-label--type-inline'>GP<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_8_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.3' type='checkbox'  value='Consultant'  id='choice_3_8_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_3' id='label_3_8_3' class='gform-field-label gform-field-label--type-inline'>Consultant<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_8_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.4' type='checkbox'  value='Other Healthcare Professional'  id='choice_3_8_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_4' id='label_3_8_4' class='gform-field-label gform-field-label--type-inline'>Other Healthcare Professional<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_8_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.5' type='checkbox'  value='Hospital\/Clinic'  id='choice_3_8_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_5' id='label_3_8_5' class='gform-field-label gform-field-label--type-inline'>Hospital\/Clinic<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_8_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.6' type='checkbox'  value='Family\/Friend'  id='choice_3_8_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_6' id='label_3_8_6' class='gform-field-label gform-field-label--type-inline'>Family\/Friend<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_9\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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 gfield_label_before_complex' >Acceptance of terms<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_3_9'><li class='gchoice gchoice_3_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Acceptance of terms'  id='choice_3_9_1'   aria-describedby=\"gfield_description_3_9\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_1' id='label_3_9_1' class='gform-field-label gform-field-label--type-inline'>Acceptance of terms<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_3_9'>By selecting you are confirming that you have read and accept our privacy policy in respect to the treatment of your data<\/div><\/li><li id=\"field_3_15\" class=\"gfield gfield--type-uid gfield--input-type-uid field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><label class='gfield_label gform-field-label' for='input_3_15'>Case Number - Unique ID<\/label><div class='ginput_container ginput_container_hidden'><input name='input_15' id='input_3_15' type='hidden' value=''  \/><\/div><\/li><\/ul><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_3' 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='submit' id='gform_submit_button_3' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit' 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class='gform_hidden' name='state_3' value='WyJbXSIsIjBhZjUyMDcxMTE2ZjgwODcyNjZlNzQ4ZjQ0MjAxNjQ2Il0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_3' id='gform_target_page_number_3' value='2' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_3' id='gform_source_page_number_3' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n             <\/div><\/div>\n                        <\/form>\n                        <\/div><script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 3, 'https:\/\/www.medelit.com\/uk\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_3').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_3');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_3').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_3').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_3').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_3').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_3').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_3').val();gformInitSpinner( 3, 'https:\/\/www.medelit.com\/uk\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [3, current_page]);window['gf_submitting_3'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_3').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_3').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [3]);window['gf_submitting_3'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_3').text());}else{jQuery('#gform_3').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"3\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {            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attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} );\n<\/script>\n<\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-4 fusion-flex-container hundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-background-position:left top;--awb-border-sizes-top:0px;--awb-border-sizes-bottom:0px;--awb-border-sizes-left:0px;--awb-border-sizes-right:0px;--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:90px;--awb-padding-right:30px;--awb-padding-bottom:20px;--awb-padding-left:30px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_1 1_1 fusion-flex-column fusion-flex-align-self-flex-start fusion-column-no-min-height\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-5\"><p style=\"text-align: center;\"><span style=\"font-size: 36pt; font-family: georgia, palatino, serif; color: #000000;\">TERMS AND CONDITIONS:<\/span><\/p>\n<\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-7 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:3.84%;--awb-width-medium:50%;--awb-spacing-right-medium:3.84%;--awb-spacing-left-medium:3.84%;--awb-width-small:100%;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"accordian fusion-accordian\" style=\"--awb-border-size:1px;--awb-icon-size:13px;--awb-content-font-size:16px;--awb-icon-alignment:left;--awb-hover-color:#f9f9f9;--awb-border-color:#cccccc;--awb-background-color:#ffffff;--awb-divider-color:#e0dede;--awb-divider-hover-color:#e0dede;--awb-icon-color:#ffffff;--awb-title-color:#ca1517;--awb-content-color:#000000;--awb-icon-box-color:#333333;--awb-toggle-hover-accent-color:#ca1517;--awb-title-font-family:&quot;Raleway&quot;;--awb-title-font-weight:400;--awb-title-font-style:normal;--awb-title-font-size:16px;--awb-title-letter-spacing:0.25px;--awb-title-line-height:1.54;--awb-content-font-family:&quot;Raleway&quot;;--awb-content-font-style:normal;--awb-content-font-weight:regular;\"><div class=\"panel-group fusion-toggle-icon-boxed\" id=\"accordion-427-3\"><div class=\"fusion-panel panel-default panel-69c3f8a3d6ab81af0 fusion-toggle-has-divider\" style=\"--awb-title-color:#ca1517;\"><div class=\"panel-heading\"><h4 class=\"panel-title toggle\" id=\"toggle_69c3f8a3d6ab81af0\"><a aria-expanded=\"false\" aria-controls=\"69c3f8a3d6ab81af0\" role=\"button\" data-toggle=\"collapse\" data-parent=\"#accordion-427-3\" data-target=\"#69c3f8a3d6ab81af0\" href=\"#69c3f8a3d6ab81af0\"><span class=\"fusion-toggle-icon-wrapper\" aria-hidden=\"true\"><i class=\"fa-fusion-box active-icon awb-icon-minus\" aria-hidden=\"true\"><\/i><i class=\"fa-fusion-box inactive-icon awb-icon-plus\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-toggle-heading\">PAYMENT METHODS<\/span><\/a><\/h4><\/div><div id=\"69c3f8a3d6ab81af0\" class=\"panel-collapse collapse \" aria-labelledby=\"toggle_69c3f8a3d6ab81af0\"><div class=\"panel-body toggle-content fusion-clearfix\">\n<p>Payment can be made in GBP only, by:<\/p>\n<ul>\n<li style=\"text-align: justify;\">DEBIT AND CREDIT CARD:<br \/>\nYour credit card information will be processed securely. Please take notice that credit\/debit card refunds may be subject to non-refundable commissions in case of a cancellation.<\/li>\n<\/ul>\n<ul>\n<li>PAYPAL<\/li>\n<\/ul>\n<p>Please take notice that our clinicians do not take cash payments.<\/p>\n<p>Your invoice will be sent by email at the address you will provide in your booking.<\/p>\n<\/div><\/div><\/div><div class=\"fusion-panel panel-default panel-945e4d86a15685efc fusion-toggle-has-divider\"><div class=\"panel-heading\"><h4 class=\"panel-title toggle\" id=\"toggle_945e4d86a15685efc\"><a aria-expanded=\"false\" aria-controls=\"945e4d86a15685efc\" role=\"button\" data-toggle=\"collapse\" data-parent=\"#accordion-427-3\" data-target=\"#945e4d86a15685efc\" href=\"#945e4d86a15685efc\"><span class=\"fusion-toggle-icon-wrapper\" aria-hidden=\"true\"><i class=\"fa-fusion-box active-icon awb-icon-minus\" aria-hidden=\"true\"><\/i><i class=\"fa-fusion-box inactive-icon awb-icon-plus\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-toggle-heading\">PRICES AND DISCOUNTS<\/span><\/a><\/h4><\/div><div id=\"945e4d86a15685efc\" class=\"panel-collapse collapse \" aria-labelledby=\"toggle_945e4d86a15685efc\"><div class=\"panel-body toggle-content fusion-clearfix\">\n<p style=\"text-align: justify;\">Medelit only recruits the best and most experienced professionals in its home visiting team.<\/p>\n<p style=\"text-align: justify;\">Fees may vary from one Professional to another and for different areas of London. These differences reflect the high levels of expertise of our professionals, the costs of travel and time that have to be covered to provide the service directly in your home and the quality of the services we provide.<\/p>\n<p style=\"text-align: justify;\">However, the higher costs for a house call are amply repaid by the invaluable advantages of receiving dedicated care in your own timing, in the privacy and comfort of your home, with the best and most highly qualified healthcare professionals in London and\u00a0without struggling\u00a0through the city&#8217;s\u00a0traffic and parking issues.<\/p>\n<p style=\"text-align: justify;\">Medelit also provides many packages\u00a0and discounted services.<\/p>\n<p style=\"text-align: justify;\">Call us or send us an email to request further information. We will supply you with information on the best solution available according to your needs.<\/p>\n<\/div><\/div><\/div><div class=\"fusion-panel panel-default panel-52e5220572b8aad74 fusion-toggle-has-divider\"><div class=\"panel-heading\"><h4 class=\"panel-title toggle\" id=\"toggle_52e5220572b8aad74\"><a aria-expanded=\"false\" aria-controls=\"52e5220572b8aad74\" role=\"button\" data-toggle=\"collapse\" data-parent=\"#accordion-427-3\" data-target=\"#52e5220572b8aad74\" href=\"#52e5220572b8aad74\"><span class=\"fusion-toggle-icon-wrapper\" aria-hidden=\"true\"><i class=\"fa-fusion-box active-icon awb-icon-minus\" aria-hidden=\"true\"><\/i><i class=\"fa-fusion-box inactive-icon awb-icon-plus\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-toggle-heading\">SERVICE PROVISION CONDITIONS<\/span><\/a><\/h4><\/div><div id=\"52e5220572b8aad74\" class=\"panel-collapse collapse \" aria-labelledby=\"toggle_52e5220572b8aad74\"><div class=\"panel-body toggle-content fusion-clearfix\">\n<p>Anyone can have an emergency, and that includes our Healthcare Professionals.<\/p>\n<p style=\"text-align: justify;\">In case of an unforeseen emergency, a healthcare professional may need to cancel a confirmed appointment. Please take notice that Medelit is a home healthcare service, not an emergency service or Hospital with 24\/24hr on-site staff. We also do not offer pharmacy services, hence for any drug\/IV administration or wound care, necessary medications and\/or materials will need to be provided by yourself and be ready at hand for the arrival of the clinician.<\/p>\n<p>In these cases, as soon as we are informed, we will immediately seek a substitution for the booked service; we cannot however unfortunately guarantee that this will be at the same date and\/or time as the confirmed appointment.<\/p>\n<p>A full refund will be provided in those cases where you are not happy with the alternative date and time for your new appointment proposals.<\/p>\n<\/div><\/div><\/div><div class=\"fusion-panel panel-default panel-9ed71f4bb6bbe86bb fusion-toggle-has-divider\"><div class=\"panel-heading\"><h4 class=\"panel-title toggle\" id=\"toggle_9ed71f4bb6bbe86bb\"><a aria-expanded=\"false\" aria-controls=\"9ed71f4bb6bbe86bb\" role=\"button\" data-toggle=\"collapse\" data-parent=\"#accordion-427-3\" data-target=\"#9ed71f4bb6bbe86bb\" href=\"#9ed71f4bb6bbe86bb\"><span class=\"fusion-toggle-icon-wrapper\" aria-hidden=\"true\"><i class=\"fa-fusion-box active-icon awb-icon-minus\" aria-hidden=\"true\"><\/i><i class=\"fa-fusion-box inactive-icon awb-icon-plus\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-toggle-heading\">CANCELLATION POLICY<\/span><\/a><\/h4><\/div><div id=\"9ed71f4bb6bbe86bb\" class=\"panel-collapse collapse \" aria-labelledby=\"toggle_9ed71f4bb6bbe86bb\"><div class=\"panel-body toggle-content fusion-clearfix\">\n<p style=\"text-align: justify;\">By making the payment to confirm your booking, you acknowledge that you have read and agree to the following terms and conditions. Requests for rescheduling and cancellations will be treated in the same manner.<\/p>\n<p style=\"text-align: justify;\">Cancellations of appointments at more than 48 hours before the scheduled time will be subject to a 10,00\u00a3 admin fee and any additional bank\/commission costs.<\/p>\n<p style=\"text-align: justify;\">A 50% cancellation fee will be applied if you cancel your confirmed appointment between 48\u00a0hours and 24 hours before the scheduled time of your appointment.<\/p>\n<p style=\"text-align: justify;\">Please note that the visit will have to be paid in full when we receive a cancellation request at \u00a024 hours or less from your scheduled appointment, or if you are not there when the healthcare professional arrives for your scheduled appointment (be it in person or remote).<\/p>\n<p>Unused treatment sessions within packages that are canceled before termination can be refunded on request, prior to fee adjustment to the full treatment price of delivered sessions.<\/p>\n<p>In case of home visits where the clinician does not find necessary drugs\/materials in your home on arrival (and can therefore not complete the service) are subject to full payment.<\/p>\n<\/div><\/div><\/div><div class=\"fusion-panel panel-default panel-2d1d4289b075e515f fusion-toggle-has-divider\"><div class=\"panel-heading\"><h4 class=\"panel-title toggle\" id=\"toggle_2d1d4289b075e515f\"><a aria-expanded=\"false\" aria-controls=\"2d1d4289b075e515f\" role=\"button\" data-toggle=\"collapse\" data-parent=\"#accordion-427-3\" data-target=\"#2d1d4289b075e515f\" href=\"#2d1d4289b075e515f\"><span class=\"fusion-toggle-icon-wrapper\" aria-hidden=\"true\"><i class=\"fa-fusion-box active-icon awb-icon-minus\" aria-hidden=\"true\"><\/i><i class=\"fa-fusion-box inactive-icon awb-icon-plus\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-toggle-heading\">HOW TO CONTACT US FOR APPOINTMENT CHANGES<\/span><\/a><\/h4><\/div><div id=\"2d1d4289b075e515f\" class=\"panel-collapse collapse \" aria-labelledby=\"toggle_2d1d4289b075e515f\"><div class=\"panel-body toggle-content fusion-clearfix\">\n<p style=\"text-align: justify;\">If you need to request a change or cancel your\u00a0appointment with us you can call us.<\/p>\n<p style=\"text-align: justify;\">If you need a change in your appointment timing we will do our best to fulfill your request.<\/p>\n<p style=\"text-align: justify;\">However, appointments changed at less than 48 hours from the scheduled time will be considered as cancellations and are therefore subject to a cancellation fee.<\/p>\n<p style=\"text-align: justify;\">Our emails are monitored <strong>24\/24hrs.<\/strong> If you need to change or cancel an appointment, please do so by sending us an <a href=\"https:\/\/www.medelit.com\/uk\/contact-us\/book-home-visit\/\">email<\/a>.<\/p>\n<\/div><\/div><\/div><div class=\"fusion-panel panel-default panel-5bd380725fabbf161 fusion-toggle-has-divider\"><div class=\"panel-heading\"><h4 class=\"panel-title toggle\" id=\"toggle_5bd380725fabbf161\"><a aria-expanded=\"false\" aria-controls=\"5bd380725fabbf161\" role=\"button\" data-toggle=\"collapse\" data-parent=\"#accordion-427-3\" data-target=\"#5bd380725fabbf161\" href=\"#5bd380725fabbf161\"><span class=\"fusion-toggle-icon-wrapper\" aria-hidden=\"true\"><i class=\"fa-fusion-box active-icon awb-icon-minus\" aria-hidden=\"true\"><\/i><i class=\"fa-fusion-box inactive-icon awb-icon-plus\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-toggle-heading\">IF YOU ARE NOT HAPPY WITH US<\/span><\/a><\/h4><\/div><div id=\"5bd380725fabbf161\" class=\"panel-collapse collapse \" aria-labelledby=\"toggle_5bd380725fabbf161\"><div class=\"panel-body toggle-content fusion-clearfix\">\n<p>If you were to have a complaint, we want to make the process very easy for you. Please send us an <a href=\"booking@medelit.com\">email<\/a> and we will recontact you, send you our complaints policy and assist you in every step of the process.<\/p>\n<p>Please take notice that Medelit is an introductory service. We strictly monitor the quality of services provided by our booking team and by the clinicians listed on our website and do so mainly through patient feedback which we use regularly to improve the quality of services. However, we are not responsible for the care provided by the independent healthcare professionals registered on our website.<\/p>\n<\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":153,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"100-width.php","meta":{"footnotes":""},"class_list":["post-427","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.7 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Book a Home or Online Visit - Medelit House Call Medical Service<\/title>\n<meta name=\"description\" content=\"Book a Home Visit in London, Greater London &amp; Liverpool - GP, Nurses, Consultants, Acupuncture, Podiatry, Physiotherapy &amp; more MEDELIT UK - Tel 020 36375657\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.medelit.com\/uk\/contact-us\/book-home-visit\/\" \/>\n<meta property=\"og:locale\" content=\"en_GB\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Book a Home or Online Visit - 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