{"id":2074,"date":"2025-12-16T17:48:50","date_gmt":"2025-12-16T17:48:50","guid":{"rendered":"https:\/\/genoks.com.tr\/?page_id=2074"},"modified":"2025-12-16T17:48:53","modified_gmt":"2025-12-16T17:48:53","slug":"wes-ces-panel-patient-information-and-consent-form","status":"publish","type":"page","link":"https:\/\/genoks.com.tr\/en\/wes-ces-panel-patient-information-and-consent-form\/","title":{"rendered":"WES\/CES\/PANEL Patient Information and Consent Form"},"content":{"rendered":"\n<div class=\"forminator-guttenberg\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-2073 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-2073\" data-uid=\"69e7877b9d53c\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-2073\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-2073 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"2073\"\n\t\t\t\t data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"69e7877b9d53c\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div role=\"tablist\" class=\"forminator-pagination-steps\" aria-label=\"Pagination\"><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-2073--page-0\"\n\t\t\t\tclass=\"forminator-pagination forminator-pagination-start\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2073--page-0-label\"\n\t\t\t\tdata-step=\"0\"\n\t\t\t\tdata-label=\"Finish\"\n\t\t\t\tdata-actual-label=\"Page 1\"\n\t\t\t\tdata-name=\"page-break-1\"\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"group-1\" class=\"forminator-field-group forminator-col forminator-col-12 \"><label class=\"forminator-label forminator-repeater-label\">Field Group<\/label><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:true,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-picker_69e7877b9d53c\" id=\"forminator-field-date-3-picker_69e7877b9d53c-label\" class=\"forminator-label\">Sampling Date<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-3\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-3-picker_69e7877b9d53c\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69e7877b9d53c\" id=\"forminator-field-name-1_69e7877b9d53c-label\" class=\"forminator-label\">Name<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_69e7877b9d53c\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69e7877b9d53c\" id=\"forminator-field-phone-1_69e7877b9d53c-label\" class=\"forminator-label\">ID No<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69e7877b9d53c\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69e7877b9d53c\" id=\"forminator-field-date-1-picker_69e7877b9d53c-label\" class=\"forminator-label\">Date of Birth<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_69e7877b9d53c\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-6 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-69e7877b9d53c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-69e7877b9d53c-label\" class=\"forminator-label\">Gender<\/span><label id=\"forminator-field-checkbox-1-1-69e7877b9d53c-label\" for=\"forminator-field-checkbox-1-1-69e7877b9d53c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Male\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-1-1-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Male<\/span><\/label><label id=\"forminator-field-checkbox-1-2-69e7877b9d53c-label\" for=\"forminator-field-checkbox-1-2-69e7877b9d53c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Female\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"two\" id=\"forminator-field-checkbox-1-2-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-1-2-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Female<\/span><\/label><\/div><\/div><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2073__field--select-1_69e7877b9d53c\" id=\"forminator-form-2073__field--select-1_69e7877b9d53c-label\" class=\"forminator-label\">Sampling Location<\/label><select  id=\"forminator-form-2073__field--select-1_69e7877b9d53c\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-1\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"\" data-search=\"false\" data-search-placeholder=\"\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2073__field--select-1_69e7877b9d53c-label\"><option value=\"Afghanistan\"  data-calculation=\"0\">Afghanistan<\/option><option value=\"Albania\"  data-calculation=\"0\">Albania<\/option><option value=\"Algeria\"  data-calculation=\"0\">Algeria<\/option><option value=\"American Samoa\"  data-calculation=\"0\">American Samoa<\/option><option value=\"Andorra\"  data-calculation=\"0\">Andorra<\/option><option value=\"Angola\"  data-calculation=\"0\">Angola<\/option><option value=\"Anguilla\"  data-calculation=\"0\">Anguilla<\/option><option value=\"Antigua and Barbuda\"  data-calculation=\"0\">Antigua and Barbuda<\/option><option value=\"Argentina\"  data-calculation=\"0\">Argentina<\/option><option value=\"Armenia\"  data-calculation=\"0\">Armenia<\/option><option value=\"Aruba\"  data-calculation=\"0\">Aruba<\/option><option value=\"Australia\"  data-calculation=\"0\">Australia<\/option><option value=\"Austria\"  data-calculation=\"0\">Austria<\/option><option value=\"Azerbaijan\"  data-calculation=\"0\">Azerbaijan<\/option><option value=\"Bahamas\"  data-calculation=\"0\">Bahamas<\/option><option value=\"Bahrain\"  data-calculation=\"0\">Bahrain<\/option><option value=\"Bangladesh\"  data-calculation=\"0\">Bangladesh<\/option><option value=\"Barbados\"  data-calculation=\"0\">Barbados<\/option><option value=\"Belarus\"  data-calculation=\"0\">Belarus<\/option><option value=\"Belgium\"  data-calculation=\"0\">Belgium<\/option><option value=\"Belize\"  data-calculation=\"0\">Belize<\/option><option value=\"Benin\"  data-calculation=\"0\">Benin<\/option><option value=\"Bermuda\"  data-calculation=\"0\">Bermuda<\/option><option value=\"Bhutan\"  data-calculation=\"0\">Bhutan<\/option><option value=\"Bolivia\"  data-calculation=\"0\">Bolivia<\/option><option value=\"Bosnia and Herzegovina\"  data-calculation=\"0\">Bosnia and Herzegovina<\/option><option value=\"Botswana\"  data-calculation=\"0\">Botswana<\/option><option value=\"Brazil\"  data-calculation=\"0\">Brazil<\/option><option value=\"British Virgin Islands\"  data-calculation=\"0\">British Virgin Islands<\/option><option value=\"Brunei\"  data-calculation=\"0\">Brunei<\/option><option value=\"Bulgaria\"  data-calculation=\"0\">Bulgaria<\/option><option value=\"Burkina Faso\"  data-calculation=\"0\">Burkina Faso<\/option><option value=\"Burundi\"  data-calculation=\"0\">Burundi<\/option><option value=\"Cabo Verde\"  data-calculation=\"0\">Cabo Verde<\/option><option value=\"Cambodia\"  data-calculation=\"0\">Cambodia<\/option><option value=\"Cameroon\"  data-calculation=\"0\">Cameroon<\/option><option value=\"Canada\"  data-calculation=\"0\">Canada<\/option><option value=\"Cayman Islands\"  data-calculation=\"0\">Cayman Islands<\/option><option value=\"Central African Republic\"  data-calculation=\"0\">Central African Republic<\/option><option value=\"Chad\"  data-calculation=\"0\">Chad<\/option><option value=\"Chile\"  data-calculation=\"0\">Chile<\/option><option value=\"China\"  data-calculation=\"0\">China<\/option><option value=\"Colombia\"  data-calculation=\"0\">Colombia<\/option><option value=\"Comoros\"  data-calculation=\"0\">Comoros<\/option><option value=\"Congo (Brazzaville)\"  data-calculation=\"0\">Congo (Brazzaville)<\/option><option value=\"Congo, Democratic Republic of the\"  data-calculation=\"0\">Congo, Democratic Republic of the<\/option><option value=\"Cook Islands\"  data-calculation=\"0\">Cook Islands<\/option><option value=\"Costa Rica\"  data-calculation=\"0\">Costa Rica<\/option><option value=\"C\u00f4te d&#039;Ivoire (Ivory Coast)\"  data-calculation=\"0\">C\u00f4te d'Ivoire (Ivory Coast)<\/option><option value=\"Croatia\"  data-calculation=\"0\">Croatia<\/option><option value=\"Cuba\"  data-calculation=\"0\">Cuba<\/option><option value=\"Cura\u00e7ao\"  data-calculation=\"0\">Cura\u00e7ao<\/option><option value=\"Cyprus\"  data-calculation=\"0\">Cyprus<\/option><option value=\"Czechia (Czech Republic)\"  data-calculation=\"0\">Czechia (Czech Republic)<\/option><option value=\"Denmark\"  data-calculation=\"0\">Denmark<\/option><option value=\"Djibouti\"  data-calculation=\"0\">Djibouti<\/option><option value=\"Dominica\"  data-calculation=\"0\">Dominica<\/option><option value=\"Dominican Republic\"  data-calculation=\"0\">Dominican Republic<\/option><option value=\"East Timor (Timor-Leste)\"  data-calculation=\"0\">East Timor (Timor-Leste)<\/option><option value=\"Ecuador\"  data-calculation=\"0\">Ecuador<\/option><option value=\"Egypt\"  data-calculation=\"0\">Egypt<\/option><option value=\"El Salvador\"  data-calculation=\"0\">El Salvador<\/option><option value=\"Equatorial Guinea\"  data-calculation=\"0\">Equatorial Guinea<\/option><option value=\"Eritrea\"  data-calculation=\"0\">Eritrea<\/option><option value=\"Estonia\"  data-calculation=\"0\">Estonia<\/option><option value=\"Eswatini\"  data-calculation=\"0\">Eswatini<\/option><option value=\"Ethiopia\"  data-calculation=\"0\">Ethiopia<\/option><option value=\"Falkland Islands\"  data-calculation=\"0\">Falkland Islands<\/option><option value=\"Faroe Islands\"  data-calculation=\"0\">Faroe Islands<\/option><option value=\"Fiji\"  data-calculation=\"0\">Fiji<\/option><option value=\"Finland\"  data-calculation=\"0\">Finland<\/option><option value=\"France\"  data-calculation=\"0\">France<\/option><option value=\"French Guiana\"  data-calculation=\"0\">French Guiana<\/option><option value=\"French Polynesia\"  data-calculation=\"0\">French Polynesia<\/option><option value=\"Gabon\"  data-calculation=\"0\">Gabon<\/option><option value=\"Gambia\"  data-calculation=\"0\">Gambia<\/option><option value=\"Georgia\"  data-calculation=\"0\">Georgia<\/option><option value=\"Germany\"  data-calculation=\"0\">Germany<\/option><option value=\"Ghana\"  data-calculation=\"0\">Ghana<\/option><option value=\"Gibraltar\"  data-calculation=\"0\">Gibraltar<\/option><option value=\"Greece\"  data-calculation=\"0\">Greece<\/option><option value=\"Greenland\"  data-calculation=\"0\">Greenland<\/option><option value=\"Grenada\"  data-calculation=\"0\">Grenada<\/option><option value=\"Guadeloupe\"  data-calculation=\"0\">Guadeloupe<\/option><option value=\"Guam\"  data-calculation=\"0\">Guam<\/option><option value=\"Guatemala\"  data-calculation=\"0\">Guatemala<\/option><option value=\"Guinea\"  data-calculation=\"0\">Guinea<\/option><option value=\"Guinea-Bissau\"  data-calculation=\"0\">Guinea-Bissau<\/option><option value=\"Guyana\"  data-calculation=\"0\">Guyana<\/option><option value=\"Haiti\"  data-calculation=\"0\">Haiti<\/option><option value=\"Honduras\"  data-calculation=\"0\">Honduras<\/option><option value=\"Hong Kong\"  data-calculation=\"0\">Hong Kong<\/option><option value=\"Hungary\"  data-calculation=\"0\">Hungary<\/option><option value=\"Iceland\"  data-calculation=\"0\">Iceland<\/option><option value=\"India\"  data-calculation=\"0\">India<\/option><option value=\"Indonesia\"  data-calculation=\"0\">Indonesia<\/option><option value=\"Iran\"  data-calculation=\"0\">Iran<\/option><option value=\"Iraq\"  data-calculation=\"0\">Iraq<\/option><option value=\"Ireland\"  data-calculation=\"0\">Ireland<\/option><option value=\"Israel\"  data-calculation=\"0\">Israel<\/option><option value=\"Italy\"  data-calculation=\"0\">Italy<\/option><option value=\"Jamaica\"  data-calculation=\"0\">Jamaica<\/option><option value=\"Japan\"  data-calculation=\"0\">Japan<\/option><option value=\"Jordan\"  data-calculation=\"0\">Jordan<\/option><option value=\"Kazakhstan\"  data-calculation=\"0\">Kazakhstan<\/option><option value=\"Kenya\"  data-calculation=\"0\">Kenya<\/option><option value=\"Kiribati\"  data-calculation=\"0\">Kiribati<\/option><option value=\"Kuwait\"  data-calculation=\"0\">Kuwait<\/option><option value=\"Kyrgyzstan\"  data-calculation=\"0\">Kyrgyzstan<\/option><option value=\"Laos\"  data-calculation=\"0\">Laos<\/option><option value=\"Latvia\"  data-calculation=\"0\">Latvia<\/option><option value=\"Lebanon\"  data-calculation=\"0\">Lebanon<\/option><option value=\"Lesotho\"  data-calculation=\"0\">Lesotho<\/option><option value=\"Liberia\"  data-calculation=\"0\">Liberia<\/option><option value=\"Libya\"  data-calculation=\"0\">Libya<\/option><option value=\"Liechtenstein\"  data-calculation=\"0\">Liechtenstein<\/option><option value=\"Lithuania\"  data-calculation=\"0\">Lithuania<\/option><option value=\"Luxembourg\"  data-calculation=\"0\">Luxembourg<\/option><option value=\"Macao\"  data-calculation=\"0\">Macao<\/option><option value=\"Madagascar\"  data-calculation=\"0\">Madagascar<\/option><option value=\"Malawi\"  data-calculation=\"0\">Malawi<\/option><option value=\"Malaysia\"  data-calculation=\"0\">Malaysia<\/option><option value=\"Maldives\"  data-calculation=\"0\">Maldives<\/option><option value=\"Mali\"  data-calculation=\"0\">Mali<\/option><option value=\"Malta\"  data-calculation=\"0\">Malta<\/option><option value=\"Marshall Islands\"  data-calculation=\"0\">Marshall Islands<\/option><option value=\"Martinique\"  data-calculation=\"0\">Martinique<\/option><option value=\"Mauritania\"  data-calculation=\"0\">Mauritania<\/option><option value=\"Mauritius\"  data-calculation=\"0\">Mauritius<\/option><option value=\"Mayotte\"  data-calculation=\"0\">Mayotte<\/option><option value=\"Mexico\"  data-calculation=\"0\">Mexico<\/option><option value=\"Micronesia (Federated States of)\"  data-calculation=\"0\">Micronesia (Federated States of)<\/option><option value=\"Moldova\"  data-calculation=\"0\">Moldova<\/option><option value=\"Monaco\"  data-calculation=\"0\">Monaco<\/option><option value=\"Mongolia\"  data-calculation=\"0\">Mongolia<\/option><option value=\"Montenegro\"  data-calculation=\"0\">Montenegro<\/option><option value=\"Montserrat\"  data-calculation=\"0\">Montserrat<\/option><option value=\"Morocco\"  data-calculation=\"0\">Morocco<\/option><option value=\"Mozambique\"  data-calculation=\"0\">Mozambique<\/option><option value=\"Myanmar (Burma)\"  data-calculation=\"0\">Myanmar (Burma)<\/option><option value=\"Namibia\"  data-calculation=\"0\">Namibia<\/option><option value=\"Nauru\"  data-calculation=\"0\">Nauru<\/option><option value=\"Nepal\"  data-calculation=\"0\">Nepal<\/option><option value=\"Netherlands\"  data-calculation=\"0\">Netherlands<\/option><option value=\"New Caledonia\"  data-calculation=\"0\">New Caledonia<\/option><option value=\"New Zealand\"  data-calculation=\"0\">New Zealand<\/option><option value=\"Nicaragua\"  data-calculation=\"0\">Nicaragua<\/option><option value=\"Niger\"  data-calculation=\"0\">Niger<\/option><option value=\"Nigeria\"  data-calculation=\"0\">Nigeria<\/option><option value=\"Niue\"  data-calculation=\"0\">Niue<\/option><option value=\"North Korea\"  data-calculation=\"0\">North Korea<\/option><option value=\"North Macedonia\"  data-calculation=\"0\">North Macedonia<\/option><option value=\"Norway\"  data-calculation=\"0\">Norway<\/option><option value=\"Oman\"  data-calculation=\"0\">Oman<\/option><option value=\"Pakistan\"  data-calculation=\"0\">Pakistan<\/option><option value=\"Palau\"  data-calculation=\"0\">Palau<\/option><option value=\"Palestine\"  data-calculation=\"0\">Palestine<\/option><option value=\"Panama\"  data-calculation=\"0\">Panama<\/option><option value=\"Papua New Guinea\"  data-calculation=\"0\">Papua New Guinea<\/option><option value=\"Paraguay\"  data-calculation=\"0\">Paraguay<\/option><option value=\"Peru\"  data-calculation=\"0\">Peru<\/option><option value=\"Philippines\"  data-calculation=\"0\">Philippines<\/option><option value=\"Pitcairn Islands\"  data-calculation=\"0\">Pitcairn Islands<\/option><option value=\"Poland\"  data-calculation=\"0\">Poland<\/option><option value=\"Portugal\"  data-calculation=\"0\">Portugal<\/option><option value=\"Puerto Rico\"  data-calculation=\"0\">Puerto Rico<\/option><option value=\"Qatar\"  data-calculation=\"0\">Qatar<\/option><option value=\"R\u00e9union\"  data-calculation=\"0\">R\u00e9union<\/option><option value=\"Romania\"  data-calculation=\"0\">Romania<\/option><option value=\"Russia\"  data-calculation=\"0\">Russia<\/option><option value=\"Rwanda\"  data-calculation=\"0\">Rwanda<\/option><option value=\"Saint Barth\u00e9lemy\"  data-calculation=\"0\">Saint Barth\u00e9lemy<\/option><option value=\"Saint Helena, Ascension and Tristan da Cunha\"  data-calculation=\"0\">Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"Saint Kitts and Nevis\"  data-calculation=\"0\">Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\"  data-calculation=\"0\">Saint Lucia<\/option><option value=\"Saint Martin\"  data-calculation=\"0\">Saint Martin<\/option><option value=\"Saint Pierre and Miquelon\"  data-calculation=\"0\">Saint Pierre and Miquelon<\/option><option value=\"Saint Vincent and the Grenadines\"  data-calculation=\"0\">Saint Vincent and the Grenadines<\/option><option value=\"Samoa\"  data-calculation=\"0\">Samoa<\/option><option value=\"San Marino\"  data-calculation=\"0\">San Marino<\/option><option value=\"Sao Tome and Principe\"  data-calculation=\"0\">Sao Tome and Principe<\/option><option value=\"Saudi Arabia\"  data-calculation=\"0\">Saudi Arabia<\/option><option value=\"Senegal\"  data-calculation=\"0\">Senegal<\/option><option value=\"Serbia\"  data-calculation=\"0\">Serbia<\/option><option value=\"Seychelles\"  data-calculation=\"0\">Seychelles<\/option><option value=\"Sierra Leone\"  data-calculation=\"0\">Sierra Leone<\/option><option value=\"Singapore\"  data-calculation=\"0\">Singapore<\/option><option value=\"Sint Maarten\"  data-calculation=\"0\">Sint Maarten<\/option><option value=\"Slovakia\"  data-calculation=\"0\">Slovakia<\/option><option value=\"Slovenia\"  data-calculation=\"0\">Slovenia<\/option><option value=\"Solomon Islands\"  data-calculation=\"0\">Solomon Islands<\/option><option value=\"Somalia\"  data-calculation=\"0\">Somalia<\/option><option value=\"South Africa\"  data-calculation=\"0\">South Africa<\/option><option value=\"South Korea\"  data-calculation=\"0\">South Korea<\/option><option value=\"South Sudan\"  data-calculation=\"0\">South Sudan<\/option><option value=\"Spain\"  data-calculation=\"0\">Spain<\/option><option value=\"Sri Lanka\"  data-calculation=\"0\">Sri Lanka<\/option><option value=\"Sudan\"  data-calculation=\"0\">Sudan<\/option><option value=\"Suriname\"  data-calculation=\"0\">Suriname<\/option><option value=\"Svalbard and Jan Mayen\"  data-calculation=\"0\">Svalbard and Jan Mayen<\/option><option value=\"Sweden\"  data-calculation=\"0\">Sweden<\/option><option value=\"Switzerland\"  data-calculation=\"0\">Switzerland<\/option><option value=\"Syria\"  data-calculation=\"0\">Syria<\/option><option value=\"Taiwan\"  data-calculation=\"0\">Taiwan<\/option><option value=\"Tajikistan\"  data-calculation=\"0\">Tajikistan<\/option><option value=\"Tanzania\"  data-calculation=\"0\">Tanzania<\/option><option value=\"Thailand\"  data-calculation=\"0\">Thailand<\/option><option value=\"Togo\"  data-calculation=\"0\">Togo<\/option><option value=\"Tokelau\"  data-calculation=\"0\">Tokelau<\/option><option value=\"Tonga\"  data-calculation=\"0\">Tonga<\/option><option value=\"Trinidad and Tobago\"  data-calculation=\"0\">Trinidad and Tobago<\/option><option value=\"Tunisia\"  data-calculation=\"0\">Tunisia<\/option><option value=\"Turkmenistan\"  data-calculation=\"0\">Turkmenistan<\/option><option value=\"Turks and Caicos Islands\"  data-calculation=\"0\">Turks and Caicos Islands<\/option><option value=\"Tuvalu\"  data-calculation=\"0\">Tuvalu<\/option><option value=\"Uganda\"  data-calculation=\"0\">Uganda<\/option><option value=\"Ukraine\"  data-calculation=\"0\">Ukraine<\/option><option value=\"United Arab Emirates\"  data-calculation=\"0\">United Arab Emirates<\/option><option value=\"United States\"  data-calculation=\"0\">United States<\/option><option value=\"Uruguay\"  data-calculation=\"0\">Uruguay<\/option><option value=\"Uzbekistan\"  data-calculation=\"0\">Uzbekistan<\/option><option value=\"Vanuatu\"  data-calculation=\"0\">Vanuatu<\/option><option value=\"Vatican City\"  data-calculation=\"0\">Vatican City<\/option><option value=\"Venezuela\"  data-calculation=\"0\">Venezuela<\/option><option value=\"Vietnam\"  data-calculation=\"0\">Vietnam<\/option><option value=\"Wallis and Futuna\"  data-calculation=\"0\">Wallis and Futuna<\/option><option value=\"Yemen\"  data-calculation=\"0\">Yemen<\/option><option value=\"Zambia\"  data-calculation=\"0\">Zambia<\/option><option value=\"Zimbabwe\"  data-calculation=\"0\">Zimbabwe<\/option><option value=\"```\"  data-calculation=\"0\">```<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69e7877b9d53c\" id=\"forminator-field-email-1_69e7877b9d53c-label\" class=\"forminator-label\">Email Address<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_69e7877b9d53c\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_69e7877b9d53c\" id=\"forminator-field-phone-2_69e7877b9d53c-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_69e7877b9d53c\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_69e7877b9d53c\" id=\"forminator-field-address-1-street_address_69e7877b9d53c-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_69e7877b9d53c\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-address_line_69e7877b9d53c\" id=\"forminator-field-address-1-address_line_69e7877b9d53c-label\" class=\"forminator-label\">Apartment, suite, etc<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_69e7877b9d53c\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_69e7877b9d53c\" id=\"forminator-field-address-1-city_69e7877b9d53c-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"\" id=\"forminator-field-address-1-city_69e7877b9d53c\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><div id=\"address-1-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-state_69e7877b9d53c\" id=\"forminator-field-address-1-state_69e7877b9d53c-label\" class=\"forminator-label\">State\/Province<\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"\" id=\"forminator-field-address-1-state_69e7877b9d53c\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_69e7877b9d53c\" id=\"forminator-field-address-1-zip_69e7877b9d53c-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"\" id=\"forminator-field-address-1-zip_69e7877b9d53c\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><div id=\"address-1-country\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-2073__field--address-1-country_69e7877b9d53c\" id=\"forminator-field-2073__field--address-1-country_69e7877b9d53c-label\" class=\"forminator-label\">Country<\/label><select name=\"address-1-country\" id=\"forminator-field-2073__field--address-1-country_69e7877b9d53c\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"Select country\" autocomplete=\"country-name country\" data-default-value=\"\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Albania\" data-country-code=\"AL\" >Albania<\/option><option value=\"Algeria\" data-country-code=\"DZ\" >Algeria<\/option><option value=\"American Samoa\" data-country-code=\"AS\" >American Samoa<\/option><option value=\"Andorra\" data-country-code=\"AD\" >Andorra<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctica\" data-country-code=\"AQ\" >Antarctica<\/option><option value=\"Antigua and Barbuda\" data-country-code=\"AG\" >Antigua and Barbuda<\/option><option value=\"Argentina\" data-country-code=\"AR\" >Argentina<\/option><option value=\"Armenia\" data-country-code=\"AM\" >Armenia<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Australia\" data-country-code=\"AU\" >Australia<\/option><option value=\"Austria\" data-country-code=\"AT\" >Austria<\/option><option value=\"Azerbaijan\" data-country-code=\"AZ\" >Azerbaijan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahrain\" data-country-code=\"BH\" >Bahrain<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"Barbados\" data-country-code=\"BB\" >Barbados<\/option><option value=\"Belarus\" data-country-code=\"BY\" >Belarus<\/option><option value=\"Belgium\" data-country-code=\"BE\" >Belgium<\/option><option value=\"Belize\" data-country-code=\"BZ\" >Belize<\/option><option value=\"Benin\" data-country-code=\"BJ\" >Benin<\/option><option value=\"Bermuda\" data-country-code=\"BM\" >Bermuda<\/option><option value=\"Bhutan\" data-country-code=\"BT\" >Bhutan<\/option><option value=\"Bolivia\" data-country-code=\"BO\" >Bolivia<\/option><option value=\"Bosnia and Herzegovina\" data-country-code=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"Bouvet Island\" data-country-code=\"BV\" >Bouvet Island<\/option><option value=\"Brazil\" data-country-code=\"BR\" >Brazil<\/option><option value=\"British Indian Ocean Territory\" data-country-code=\"IO\" >British Indian Ocean Territory<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brunei<\/option><option value=\"Bulgaria\" data-country-code=\"BG\" >Bulgaria<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"Cabo Verde\" data-country-code=\"CV\" >Cabo Verde<\/option><option value=\"Cambodia\" data-country-code=\"KH\" >Cambodia<\/option><option value=\"Cameroon\" data-country-code=\"CM\" >Cameroon<\/option><option value=\"Canada\" data-country-code=\"CA\" >Canada<\/option><option value=\"Cayman Islands\" data-country-code=\"KY\" >Cayman Islands<\/option><option value=\"Central African Republic\" data-country-code=\"CF\" >Central African Republic<\/option><option value=\"Chad\" data-country-code=\"TD\" >Chad<\/option><option value=\"Chile\" data-country-code=\"CL\" >Chile<\/option><option value=\"China, People's Republic of\" data-country-code=\"CN\" >China, People's Republic of<\/option><option value=\"Christmas Island\" data-country-code=\"CX\" >Christmas Island<\/option><option value=\"Cocos Islands\" data-country-code=\"CC\" >Cocos Islands<\/option><option value=\"Colombia\" data-country-code=\"CO\" >Colombia<\/option><option value=\"Comoros\" data-country-code=\"KM\" >Comoros<\/option><option value=\"Congo, Democratic Republic of the\" data-country-code=\"CD\" >Congo, Democratic Republic of the<\/option><option value=\"Congo, Republic of the\" data-country-code=\"CG\" >Congo, Republic of the<\/option><option value=\"Cook Islands\" data-country-code=\"CK\" >Cook Islands<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"Croatia\" data-country-code=\"HR\" >Croatia<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Cura\u00e7ao<\/option><option value=\"Cyprus\" data-country-code=\"CY\" >Cyprus<\/option><option value=\"Czech Republic\" data-country-code=\"CZ\" >Czech Republic<\/option><option value=\"C\u00f4te d'Ivoire\" data-country-code=\"CI\" >C\u00f4te d'Ivoire<\/option><option value=\"Denmark\" data-country-code=\"DK\" >Denmark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominica\" data-country-code=\"DM\" >Dominica<\/option><option value=\"Dominican Republic\" data-country-code=\"DO\" >Dominican Republic<\/option><option value=\"East Timor\" data-country-code=\"TL\" >East Timor<\/option><option value=\"Ecuador\" data-country-code=\"EC\" >Ecuador<\/option><option value=\"Egypt\" data-country-code=\"EG\" >Egypt<\/option><option value=\"El Salvador\" data-country-code=\"SV\" >El Salvador<\/option><option value=\"Equatorial Guinea\" data-country-code=\"GQ\" >Equatorial Guinea<\/option><option value=\"Eritrea\" data-country-code=\"ER\" >Eritrea<\/option><option value=\"Estonia\" data-country-code=\"EE\" >Estonia<\/option><option value=\"Ethiopia\" data-country-code=\"ET\" >Ethiopia<\/option><option value=\"Falkland Islands\" data-country-code=\"FK\" >Falkland Islands<\/option><option value=\"Faroe Islands\" data-country-code=\"FO\" >Faroe Islands<\/option><option value=\"Fiji\" data-country-code=\"FJ\" >Fiji<\/option><option value=\"Finland\" data-country-code=\"FI\" >Finland<\/option><option value=\"France\" data-country-code=\"FR\" >France<\/option><option value=\"France, Metropolitan\" data-country-code=\"FX\" >France, Metropolitan<\/option><option value=\"French Guiana\" data-country-code=\"GF\" >French Guiana<\/option><option value=\"French Polynesia\" data-country-code=\"PF\" >French Polynesia<\/option><option value=\"French South Territories\" data-country-code=\"TF\" >French South Territories<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambia\" data-country-code=\"GM\" >Gambia<\/option><option value=\"Georgia\" data-country-code=\"GE\" >Georgia<\/option><option value=\"Germany\" data-country-code=\"DE\" >Germany<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Greece\" data-country-code=\"GR\" >Greece<\/option><option value=\"Greenland\" data-country-code=\"GL\" >Greenland<\/option><option value=\"Grenada\" data-country-code=\"GD\" >Grenada<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guatemala\" data-country-code=\"GT\" >Guatemala<\/option><option value=\"Guernsey\" data-country-code=\"GG\" >Guernsey<\/option><option value=\"Guinea\" data-country-code=\"GN\" >Guinea<\/option><option value=\"Guinea-Bissau\" data-country-code=\"GW\" >Guinea-Bissau<\/option><option value=\"Guyana\" data-country-code=\"GY\" >Guyana<\/option><option value=\"Haiti\" data-country-code=\"HT\" >Haiti<\/option><option value=\"Heard Island And Mcdonald Island\" data-country-code=\"HM\" >Heard Island And Mcdonald Island<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong\" data-country-code=\"HK\" >Hong Kong<\/option><option value=\"Hungary\" data-country-code=\"HU\" >Hungary<\/option><option value=\"Iceland\" data-country-code=\"IS\" >Iceland<\/option><option value=\"India\" data-country-code=\"IN\" >India<\/option><option value=\"Indonesia\" data-country-code=\"ID\" >Indonesia<\/option><option value=\"Iran\" data-country-code=\"IR\" >Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >Iraq<\/option><option value=\"Ireland\" data-country-code=\"IE\" >Ireland<\/option><option value=\"Israel\" data-country-code=\"IL\" >Israel<\/option><option value=\"Italy\" data-country-code=\"IT\" >Italy<\/option><option value=\"Jamaica\" data-country-code=\"JM\" >Jamaica<\/option><option value=\"Japan\" data-country-code=\"JP\" >Japan<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"Johnston Island\" data-country-code=\"JT\" >Johnston Island<\/option><option value=\"Jordan\" data-country-code=\"JO\" >Jordan<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Korea, Democratic People's Republic of\" data-country-code=\"KP\" >Korea, Democratic People's Republic of<\/option><option value=\"Korea, Republic of\" data-country-code=\"KR\" >Korea, Republic of<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kuwait\" data-country-code=\"KW\" >Kuwait<\/option><option value=\"Kyrgyzstan\" data-country-code=\"KG\" >Kyrgyzstan<\/option><option value=\"Lao People's Democratic Republic\" data-country-code=\"LA\" >Lao People's Democratic Republic<\/option><option value=\"Latvia\" data-country-code=\"LV\" >Latvia<\/option><option value=\"Lebanon\" data-country-code=\"LB\" >Lebanon<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Liberia\" data-country-code=\"LR\" >Liberia<\/option><option value=\"Libya\" data-country-code=\"LY\" >Libya<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lithuania\" data-country-code=\"LT\" >Lithuania<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macau\" data-country-code=\"MO\" >Macau<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Malaysia\" data-country-code=\"MY\" >Malaysia<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malta\" data-country-code=\"MT\" >Malta<\/option><option value=\"Marshall Islands\" data-country-code=\"MH\" >Marshall Islands<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritania\" data-country-code=\"MR\" >Mauritania<\/option><option value=\"Mauritius\" data-country-code=\"MU\" >Mauritius<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexico\" data-country-code=\"MX\" >Mexico<\/option><option value=\"Micronesia\" data-country-code=\"FM\" >Micronesia<\/option><option value=\"Moldova\" data-country-code=\"MD\" >Moldova<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolia\" data-country-code=\"MN\" >Mongolia<\/option><option value=\"Montenegro\" data-country-code=\"ME\" >Montenegro<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Morocco\" data-country-code=\"MA\" >Morocco<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Myanmar<\/option><option value=\"Namibia\" data-country-code=\"NA\" >Namibia<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"Nepal\" data-country-code=\"NP\" >Nepal<\/option><option value=\"Netherlands\" data-country-code=\"NL\" >Netherlands<\/option><option value=\"Netherlands Antilles\" data-country-code=\"AN\" >Netherlands Antilles<\/option><option value=\"New Caledonia\" data-country-code=\"NC\" >New Caledonia<\/option><option value=\"New Zealand\" data-country-code=\"NZ\" >New Zealand<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nigeria\" data-country-code=\"NG\" >Nigeria<\/option><option value=\"Niue\" data-country-code=\"NU\" >Niue<\/option><option value=\"Norfolk Island\" data-country-code=\"NF\" >Norfolk Island<\/option><option value=\"North Macedonia\" data-country-code=\"MK\" >North Macedonia<\/option><option value=\"Northern Mariana Islands\" data-country-code=\"MP\" >Northern Mariana Islands<\/option><option value=\"Norway\" data-country-code=\"NO\" >Norway<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palau\" data-country-code=\"PW\" >Palau<\/option><option value=\"Palestine, State of\" data-country-code=\"PS\" >Palestine, State of<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papua New Guinea\" data-country-code=\"PG\" >Papua New Guinea<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"Peru\" data-country-code=\"PE\" >Peru<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"Pitcairn Islands\" data-country-code=\"PN\" >Pitcairn Islands<\/option><option value=\"Poland\" data-country-code=\"PL\" >Poland<\/option><option value=\"Portugal\" data-country-code=\"PT\" >Portugal<\/option><option value=\"Puerto Rico\" data-country-code=\"PR\" >Puerto Rico<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"Reunion Island\" data-country-code=\"RE\" >Reunion Island<\/option><option value=\"Romania\" data-country-code=\"RO\" >Romania<\/option><option value=\"Russia\" data-country-code=\"RU\" >Russia<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"Saint Helena\" data-country-code=\"SH\" >Saint Helena<\/option><option value=\"Saint Kitts and Nevis\" data-country-code=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\" data-country-code=\"LC\" >Saint Lucia<\/option><option value=\"Saint Pierre & Miquelon\" data-country-code=\"PM\" >Saint Pierre & Miquelon<\/option><option value=\"Saint Vincent and the Grenadines\" data-country-code=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"San Marino\" data-country-code=\"SM\" >San Marino<\/option><option value=\"Sao Tome and Principe\" data-country-code=\"ST\" >Sao Tome and Principe<\/option><option value=\"Saudi Arabia\" data-country-code=\"SA\" >Saudi Arabia<\/option><option value=\"Senegal\" data-country-code=\"SN\" >Senegal<\/option><option value=\"Serbia\" data-country-code=\"RS\" >Serbia<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapore\" data-country-code=\"SG\" >Singapore<\/option><option value=\"Sint Maarten\" data-country-code=\"MF\" >Sint Maarten<\/option><option value=\"Slovakia\" data-country-code=\"SK\" >Slovakia<\/option><option value=\"Slovenia\" data-country-code=\"SI\" >Slovenia<\/option><option value=\"Solomon Islands\" data-country-code=\"SB\" >Solomon Islands<\/option><option value=\"Somalia\" data-country-code=\"SO\" >Somalia<\/option><option value=\"South Africa\" data-country-code=\"ZA\" >South Africa<\/option><option value=\"South Georgia and South Sandwich\" data-country-code=\"GS\" >South Georgia and South Sandwich<\/option><option value=\"Spain\" data-country-code=\"ES\" >Spain<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"Stateless Persons\" data-country-code=\"XX\" >Stateless Persons<\/option><option value=\"Sudan\" data-country-code=\"SD\" >Sudan<\/option><option value=\"Sudan, South\" data-country-code=\"SS\" >Sudan, South<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Suriname<\/option><option value=\"Svalbard and Jan Mayen\" data-country-code=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"Swaziland\" data-country-code=\"SZ\" >Swaziland<\/option><option value=\"Sweden\" data-country-code=\"SE\" >Sweden<\/option><option value=\"Switzerland\" data-country-code=\"CH\" >Switzerland<\/option><option value=\"Syria\" data-country-code=\"SY\" >Syria<\/option><option value=\"Taiwan, Republic of China\" data-country-code=\"TW\" >Taiwan, Republic of China<\/option><option value=\"Tajikistan\" data-country-code=\"TJ\" >Tajikistan<\/option><option value=\"Tanzania\" data-country-code=\"TZ\" >Tanzania<\/option><option value=\"Thailand\" data-country-code=\"TH\" >Thailand<\/option><option value=\"Togo\" data-country-code=\"TG\" >Togo<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tokelau<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinidad and Tobago\" data-country-code=\"TT\" >Trinidad and Tobago<\/option><option value=\"Tunisia\" data-country-code=\"TN\" >Tunisia<\/option><option value=\"Turkey\" data-country-code=\"TR\" >Turkey<\/option><option value=\"Turkmenistan\" data-country-code=\"TM\" >Turkmenistan<\/option><option value=\"Turks And Caicos Islands\" data-country-code=\"TC\" >Turks And Caicos Islands<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"US Minor Outlying Islands\" data-country-code=\"UM\" >US Minor Outlying Islands<\/option><option value=\"Uganda\" data-country-code=\"UG\" >Uganda<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"United Arab Emirates\" data-country-code=\"AE\" >United Arab Emirates<\/option><option value=\"United Kingdom\" data-country-code=\"GB\" >United Kingdom<\/option><option value=\"United States of America (USA)\" data-country-code=\"US\" >United States of America (USA)<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Uzbekistan\" data-country-code=\"UZ\" >Uzbekistan<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Vatican City\" data-country-code=\"VA\" >Vatican City<\/option><option value=\"Venezuela\" data-country-code=\"VE\" >Venezuela<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vietnam<\/option><option value=\"Virgin Islands, British\" data-country-code=\"VG\" >Virgin Islands, British<\/option><option value=\"Virgin Islands, U.S.\" data-country-code=\"VI\" >Virgin Islands, U.S.<\/option><option value=\"Wallis And Futuna Islands\" data-country-code=\"WF\" >Wallis And Futuna Islands<\/option><option value=\"Western Sahara\" data-country-code=\"EH\" >Western Sahara<\/option><option value=\"Yemen\" data-country-code=\"YE\" >Yemen<\/option><option value=\"Zambia\" data-country-code=\"ZM\" >Zambia<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row forminator-action-buttons\"><div class=\"forminator-col forminator-col-12\"><input type=\"button\" value=\"Add item\" class=\"forminator-repeater-action-button forminator-repeater-add\" \/><input type=\"button\" value=\"Remove item\" class=\"forminator-repeater-action-button forminator-repeater-remove\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-2073--page-1\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2073--page-1-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"1\"\n\t\t\t\tdata-label=\"Page  1\"\n\t\t\t\tdata-actual-label=\"Page 2\"\n\t\t\t\tdata-name=\"page-break-2\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"group-2\" class=\"forminator-field-group forminator-col forminator-col-12 \"><label class=\"forminator-label forminator-repeater-label\">Physician\u2019s Informations<\/label><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:true,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_69e7877b9d53c\" id=\"forminator-field-name-2_69e7877b9d53c-label\" class=\"forminator-label\">Name<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_69e7877b9d53c\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"email-2\" class=\"forminator-field-email forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-2_69e7877b9d53c\" id=\"forminator-field-email-2_69e7877b9d53c-label\" class=\"forminator-label\">Email Address<\/label><input type=\"email\" name=\"email-2\" value=\"\" placeholder=\"\" id=\"forminator-field-email-2_69e7877b9d53c\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><div id=\"phone-3\" class=\"forminator-field-phone forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-3_69e7877b9d53c\" id=\"forminator-field-phone-3_69e7877b9d53c-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-3\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-3_69e7877b9d53c\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-2\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-2-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-street_address_69e7877b9d53c\" id=\"forminator-field-address-2-street_address_69e7877b9d53c-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-2-street_address\" placeholder=\"\" id=\"forminator-field-address-2-street_address_69e7877b9d53c\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-2-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-address_line_69e7877b9d53c\" id=\"forminator-field-address-2-address_line_69e7877b9d53c-label\" class=\"forminator-label\">Apartment, suite, etc<\/label><input type=\"text\" name=\"address-2-address_line\" placeholder=\"\" id=\"forminator-field-address-2-address_line_69e7877b9d53c\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-2-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-city_69e7877b9d53c\" id=\"forminator-field-address-2-city_69e7877b9d53c-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-2-city\" placeholder=\"\" id=\"forminator-field-address-2-city_69e7877b9d53c\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><div id=\"address-2-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-state_69e7877b9d53c\" id=\"forminator-field-address-2-state_69e7877b9d53c-label\" class=\"forminator-label\">State\/Province<\/label><input type=\"text\" name=\"address-2-state\" placeholder=\"\" id=\"forminator-field-address-2-state_69e7877b9d53c\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-2-zip\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-zip_69e7877b9d53c\" id=\"forminator-field-address-2-zip_69e7877b9d53c-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-2-zip\" placeholder=\"\" id=\"forminator-field-address-2-zip_69e7877b9d53c\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><div id=\"address-2-country\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-2073__field--address-2-country_69e7877b9d53c\" id=\"forminator-field-2073__field--address-2-country_69e7877b9d53c-label\" class=\"forminator-label\">Country<\/label><select name=\"address-2-country\" id=\"forminator-field-2073__field--address-2-country_69e7877b9d53c\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"Select country\" autocomplete=\"country-name country\" data-default-value=\"\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Albania\" data-country-code=\"AL\" >Albania<\/option><option value=\"Algeria\" data-country-code=\"DZ\" >Algeria<\/option><option value=\"American Samoa\" data-country-code=\"AS\" >American Samoa<\/option><option value=\"Andorra\" data-country-code=\"AD\" >Andorra<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctica\" data-country-code=\"AQ\" >Antarctica<\/option><option value=\"Antigua and Barbuda\" data-country-code=\"AG\" >Antigua and Barbuda<\/option><option value=\"Argentina\" data-country-code=\"AR\" >Argentina<\/option><option value=\"Armenia\" data-country-code=\"AM\" >Armenia<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Australia\" data-country-code=\"AU\" >Australia<\/option><option value=\"Austria\" data-country-code=\"AT\" >Austria<\/option><option value=\"Azerbaijan\" data-country-code=\"AZ\" >Azerbaijan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahrain\" data-country-code=\"BH\" >Bahrain<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"Barbados\" data-country-code=\"BB\" >Barbados<\/option><option value=\"Belarus\" data-country-code=\"BY\" >Belarus<\/option><option value=\"Belgium\" data-country-code=\"BE\" >Belgium<\/option><option value=\"Belize\" data-country-code=\"BZ\" >Belize<\/option><option value=\"Benin\" data-country-code=\"BJ\" >Benin<\/option><option value=\"Bermuda\" data-country-code=\"BM\" >Bermuda<\/option><option value=\"Bhutan\" data-country-code=\"BT\" >Bhutan<\/option><option value=\"Bolivia\" data-country-code=\"BO\" >Bolivia<\/option><option value=\"Bosnia and Herzegovina\" data-country-code=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"Bouvet Island\" data-country-code=\"BV\" >Bouvet Island<\/option><option value=\"Brazil\" data-country-code=\"BR\" >Brazil<\/option><option value=\"British Indian Ocean Territory\" data-country-code=\"IO\" >British Indian Ocean Territory<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brunei<\/option><option value=\"Bulgaria\" data-country-code=\"BG\" >Bulgaria<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"Cabo Verde\" data-country-code=\"CV\" >Cabo Verde<\/option><option value=\"Cambodia\" data-country-code=\"KH\" >Cambodia<\/option><option value=\"Cameroon\" data-country-code=\"CM\" >Cameroon<\/option><option value=\"Canada\" data-country-code=\"CA\" >Canada<\/option><option value=\"Cayman Islands\" data-country-code=\"KY\" >Cayman Islands<\/option><option value=\"Central African Republic\" data-country-code=\"CF\" >Central African Republic<\/option><option value=\"Chad\" data-country-code=\"TD\" >Chad<\/option><option value=\"Chile\" data-country-code=\"CL\" >Chile<\/option><option value=\"China, People's Republic of\" data-country-code=\"CN\" >China, People's Republic of<\/option><option value=\"Christmas Island\" data-country-code=\"CX\" >Christmas Island<\/option><option value=\"Cocos Islands\" data-country-code=\"CC\" >Cocos Islands<\/option><option value=\"Colombia\" data-country-code=\"CO\" >Colombia<\/option><option value=\"Comoros\" data-country-code=\"KM\" >Comoros<\/option><option value=\"Congo, Democratic Republic of the\" data-country-code=\"CD\" >Congo, Democratic Republic of the<\/option><option value=\"Congo, Republic of the\" data-country-code=\"CG\" >Congo, Republic of the<\/option><option value=\"Cook Islands\" data-country-code=\"CK\" >Cook Islands<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"Croatia\" data-country-code=\"HR\" >Croatia<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Cura\u00e7ao<\/option><option value=\"Cyprus\" data-country-code=\"CY\" >Cyprus<\/option><option value=\"Czech Republic\" data-country-code=\"CZ\" >Czech Republic<\/option><option value=\"C\u00f4te d'Ivoire\" data-country-code=\"CI\" >C\u00f4te d'Ivoire<\/option><option value=\"Denmark\" data-country-code=\"DK\" >Denmark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominica\" data-country-code=\"DM\" >Dominica<\/option><option value=\"Dominican Republic\" data-country-code=\"DO\" >Dominican Republic<\/option><option value=\"East Timor\" data-country-code=\"TL\" >East Timor<\/option><option value=\"Ecuador\" data-country-code=\"EC\" >Ecuador<\/option><option value=\"Egypt\" data-country-code=\"EG\" >Egypt<\/option><option value=\"El Salvador\" data-country-code=\"SV\" >El Salvador<\/option><option value=\"Equatorial Guinea\" data-country-code=\"GQ\" >Equatorial Guinea<\/option><option value=\"Eritrea\" data-country-code=\"ER\" >Eritrea<\/option><option value=\"Estonia\" data-country-code=\"EE\" >Estonia<\/option><option value=\"Ethiopia\" data-country-code=\"ET\" >Ethiopia<\/option><option value=\"Falkland Islands\" data-country-code=\"FK\" >Falkland Islands<\/option><option value=\"Faroe Islands\" data-country-code=\"FO\" >Faroe Islands<\/option><option value=\"Fiji\" data-country-code=\"FJ\" >Fiji<\/option><option value=\"Finland\" data-country-code=\"FI\" >Finland<\/option><option value=\"France\" data-country-code=\"FR\" >France<\/option><option value=\"France, Metropolitan\" data-country-code=\"FX\" >France, Metropolitan<\/option><option value=\"French Guiana\" data-country-code=\"GF\" >French Guiana<\/option><option value=\"French Polynesia\" data-country-code=\"PF\" >French Polynesia<\/option><option value=\"French South Territories\" data-country-code=\"TF\" >French South Territories<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambia\" data-country-code=\"GM\" >Gambia<\/option><option value=\"Georgia\" data-country-code=\"GE\" >Georgia<\/option><option value=\"Germany\" data-country-code=\"DE\" >Germany<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Greece\" data-country-code=\"GR\" >Greece<\/option><option value=\"Greenland\" data-country-code=\"GL\" >Greenland<\/option><option value=\"Grenada\" data-country-code=\"GD\" >Grenada<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guatemala\" data-country-code=\"GT\" >Guatemala<\/option><option value=\"Guernsey\" data-country-code=\"GG\" >Guernsey<\/option><option value=\"Guinea\" data-country-code=\"GN\" >Guinea<\/option><option value=\"Guinea-Bissau\" data-country-code=\"GW\" >Guinea-Bissau<\/option><option value=\"Guyana\" data-country-code=\"GY\" >Guyana<\/option><option value=\"Haiti\" data-country-code=\"HT\" >Haiti<\/option><option value=\"Heard Island And Mcdonald Island\" data-country-code=\"HM\" >Heard Island And Mcdonald Island<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong\" data-country-code=\"HK\" >Hong Kong<\/option><option value=\"Hungary\" data-country-code=\"HU\" >Hungary<\/option><option value=\"Iceland\" data-country-code=\"IS\" >Iceland<\/option><option value=\"India\" data-country-code=\"IN\" >India<\/option><option value=\"Indonesia\" data-country-code=\"ID\" >Indonesia<\/option><option value=\"Iran\" data-country-code=\"IR\" >Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >Iraq<\/option><option value=\"Ireland\" data-country-code=\"IE\" >Ireland<\/option><option value=\"Israel\" data-country-code=\"IL\" >Israel<\/option><option value=\"Italy\" data-country-code=\"IT\" >Italy<\/option><option value=\"Jamaica\" data-country-code=\"JM\" >Jamaica<\/option><option value=\"Japan\" data-country-code=\"JP\" >Japan<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"Johnston Island\" data-country-code=\"JT\" >Johnston Island<\/option><option value=\"Jordan\" data-country-code=\"JO\" >Jordan<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Korea, Democratic People's Republic of\" data-country-code=\"KP\" >Korea, Democratic People's Republic of<\/option><option value=\"Korea, Republic of\" data-country-code=\"KR\" >Korea, Republic of<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kuwait\" data-country-code=\"KW\" >Kuwait<\/option><option value=\"Kyrgyzstan\" data-country-code=\"KG\" >Kyrgyzstan<\/option><option value=\"Lao People's Democratic Republic\" data-country-code=\"LA\" >Lao People's Democratic Republic<\/option><option value=\"Latvia\" data-country-code=\"LV\" >Latvia<\/option><option value=\"Lebanon\" data-country-code=\"LB\" >Lebanon<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Liberia\" data-country-code=\"LR\" >Liberia<\/option><option value=\"Libya\" data-country-code=\"LY\" >Libya<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lithuania\" data-country-code=\"LT\" >Lithuania<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macau\" data-country-code=\"MO\" >Macau<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Malaysia\" data-country-code=\"MY\" >Malaysia<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malta\" data-country-code=\"MT\" >Malta<\/option><option value=\"Marshall Islands\" data-country-code=\"MH\" >Marshall Islands<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritania\" data-country-code=\"MR\" >Mauritania<\/option><option value=\"Mauritius\" data-country-code=\"MU\" >Mauritius<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexico\" data-country-code=\"MX\" >Mexico<\/option><option value=\"Micronesia\" data-country-code=\"FM\" >Micronesia<\/option><option value=\"Moldova\" data-country-code=\"MD\" >Moldova<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolia\" data-country-code=\"MN\" >Mongolia<\/option><option value=\"Montenegro\" data-country-code=\"ME\" >Montenegro<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Morocco\" data-country-code=\"MA\" >Morocco<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Myanmar<\/option><option value=\"Namibia\" data-country-code=\"NA\" >Namibia<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"Nepal\" data-country-code=\"NP\" >Nepal<\/option><option value=\"Netherlands\" data-country-code=\"NL\" >Netherlands<\/option><option value=\"Netherlands Antilles\" data-country-code=\"AN\" >Netherlands Antilles<\/option><option value=\"New Caledonia\" data-country-code=\"NC\" >New Caledonia<\/option><option value=\"New Zealand\" data-country-code=\"NZ\" >New Zealand<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nigeria\" data-country-code=\"NG\" >Nigeria<\/option><option value=\"Niue\" data-country-code=\"NU\" >Niue<\/option><option value=\"Norfolk Island\" data-country-code=\"NF\" >Norfolk Island<\/option><option value=\"North Macedonia\" data-country-code=\"MK\" >North Macedonia<\/option><option value=\"Northern Mariana Islands\" data-country-code=\"MP\" >Northern Mariana Islands<\/option><option value=\"Norway\" data-country-code=\"NO\" >Norway<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palau\" data-country-code=\"PW\" >Palau<\/option><option value=\"Palestine, State of\" data-country-code=\"PS\" >Palestine, State of<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papua New Guinea\" data-country-code=\"PG\" >Papua New Guinea<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"Peru\" data-country-code=\"PE\" >Peru<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"Pitcairn Islands\" data-country-code=\"PN\" >Pitcairn Islands<\/option><option value=\"Poland\" data-country-code=\"PL\" >Poland<\/option><option value=\"Portugal\" data-country-code=\"PT\" >Portugal<\/option><option value=\"Puerto Rico\" data-country-code=\"PR\" >Puerto Rico<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"Reunion Island\" data-country-code=\"RE\" >Reunion Island<\/option><option value=\"Romania\" data-country-code=\"RO\" >Romania<\/option><option value=\"Russia\" data-country-code=\"RU\" >Russia<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"Saint Helena\" data-country-code=\"SH\" >Saint Helena<\/option><option value=\"Saint Kitts and Nevis\" data-country-code=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\" data-country-code=\"LC\" >Saint Lucia<\/option><option value=\"Saint Pierre & Miquelon\" data-country-code=\"PM\" >Saint Pierre & Miquelon<\/option><option value=\"Saint Vincent and the Grenadines\" data-country-code=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"San Marino\" data-country-code=\"SM\" >San Marino<\/option><option value=\"Sao Tome and Principe\" data-country-code=\"ST\" >Sao Tome and Principe<\/option><option value=\"Saudi Arabia\" data-country-code=\"SA\" >Saudi Arabia<\/option><option value=\"Senegal\" data-country-code=\"SN\" >Senegal<\/option><option value=\"Serbia\" data-country-code=\"RS\" >Serbia<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapore\" data-country-code=\"SG\" >Singapore<\/option><option value=\"Sint Maarten\" data-country-code=\"MF\" >Sint Maarten<\/option><option value=\"Slovakia\" data-country-code=\"SK\" >Slovakia<\/option><option value=\"Slovenia\" data-country-code=\"SI\" >Slovenia<\/option><option value=\"Solomon Islands\" data-country-code=\"SB\" >Solomon Islands<\/option><option value=\"Somalia\" data-country-code=\"SO\" >Somalia<\/option><option value=\"South Africa\" data-country-code=\"ZA\" >South Africa<\/option><option value=\"South Georgia and South Sandwich\" data-country-code=\"GS\" >South Georgia and South Sandwich<\/option><option value=\"Spain\" data-country-code=\"ES\" >Spain<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"Stateless Persons\" data-country-code=\"XX\" >Stateless Persons<\/option><option value=\"Sudan\" data-country-code=\"SD\" >Sudan<\/option><option value=\"Sudan, South\" data-country-code=\"SS\" >Sudan, South<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Suriname<\/option><option value=\"Svalbard and Jan Mayen\" data-country-code=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"Swaziland\" data-country-code=\"SZ\" >Swaziland<\/option><option value=\"Sweden\" data-country-code=\"SE\" >Sweden<\/option><option value=\"Switzerland\" data-country-code=\"CH\" >Switzerland<\/option><option value=\"Syria\" data-country-code=\"SY\" >Syria<\/option><option value=\"Taiwan, Republic of China\" data-country-code=\"TW\" >Taiwan, Republic of China<\/option><option value=\"Tajikistan\" data-country-code=\"TJ\" >Tajikistan<\/option><option value=\"Tanzania\" data-country-code=\"TZ\" >Tanzania<\/option><option value=\"Thailand\" data-country-code=\"TH\" >Thailand<\/option><option value=\"Togo\" data-country-code=\"TG\" >Togo<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tokelau<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinidad and Tobago\" data-country-code=\"TT\" >Trinidad and Tobago<\/option><option value=\"Tunisia\" data-country-code=\"TN\" >Tunisia<\/option><option value=\"Turkey\" data-country-code=\"TR\" >Turkey<\/option><option value=\"Turkmenistan\" data-country-code=\"TM\" >Turkmenistan<\/option><option value=\"Turks And Caicos Islands\" data-country-code=\"TC\" >Turks And Caicos Islands<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"US Minor Outlying Islands\" data-country-code=\"UM\" >US Minor Outlying Islands<\/option><option value=\"Uganda\" data-country-code=\"UG\" >Uganda<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"United Arab Emirates\" data-country-code=\"AE\" >United Arab Emirates<\/option><option value=\"United Kingdom\" data-country-code=\"GB\" >United Kingdom<\/option><option value=\"United States of America (USA)\" data-country-code=\"US\" >United States of America (USA)<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Uzbekistan\" data-country-code=\"UZ\" >Uzbekistan<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Vatican City\" data-country-code=\"VA\" >Vatican City<\/option><option value=\"Venezuela\" data-country-code=\"VE\" >Venezuela<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vietnam<\/option><option value=\"Virgin Islands, British\" data-country-code=\"VG\" >Virgin Islands, British<\/option><option value=\"Virgin Islands, U.S.\" data-country-code=\"VI\" >Virgin Islands, U.S.<\/option><option value=\"Wallis And Futuna Islands\" data-country-code=\"WF\" >Wallis And Futuna Islands<\/option><option value=\"Western Sahara\" data-country-code=\"EH\" >Western Sahara<\/option><option value=\"Yemen\" data-country-code=\"YE\" >Yemen<\/option><option value=\"Zambia\" data-country-code=\"ZM\" >Zambia<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"url-1\" class=\"forminator-field-url forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-url-1_69e7877b9d53c\" id=\"forminator-field-url-1_69e7877b9d53c-label\" class=\"forminator-label\">Website<\/label><input type=\"url\" name=\"url-1\" value=\"\" placeholder=\"\" id=\"forminator-field-url-1_69e7877b9d53c\" class=\"forminator-input forminator-website--field\" data-required=\"\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_69e7877b9d53c\" id=\"forminator-field-textarea-1_69e7877b9d53c-label\" class=\"forminator-label\">Physician\u2019s Notes<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row forminator-action-buttons\"><div class=\"forminator-col forminator-col-12\"><input type=\"button\" value=\"Add item\" class=\"forminator-repeater-action-button forminator-repeater-add\" \/><input type=\"button\" value=\"Remove item\" class=\"forminator-repeater-action-button forminator-repeater-remove\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-2073--page-2\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2073--page-2-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"2\"\n\t\t\t\tdata-label=\"Page  2\"\n\t\t\t\tdata-actual-label=\"Page 3\"\n\t\t\t\tdata-name=\"page-break-3\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"group-3\" class=\"forminator-field-group forminator-col forminator-col-12 \"><label class=\"forminator-label forminator-repeater-label\">Anamnesis<\/label><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:true,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_69e7877b9d53c\" id=\"forminator-field-textarea-2_69e7877b9d53c-label\" class=\"forminator-label\">Complication<\/label><textarea name=\"textarea-2\" placeholder=\"\" id=\"forminator-field-textarea-2_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-6\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-6_69e7877b9d53c\" id=\"forminator-field-textarea-6_69e7877b9d53c-label\" class=\"forminator-label\">MRI<\/label><textarea name=\"textarea-6\" placeholder=\"\" id=\"forminator-field-textarea-6_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-10\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-10_69e7877b9d53c\" id=\"forminator-field-textarea-10_69e7877b9d53c-label\" class=\"forminator-label\">Eye Examination<\/label><textarea name=\"textarea-10\" placeholder=\"\" id=\"forminator-field-textarea-10_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-9\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-9_69e7877b9d53c\" id=\"forminator-field-textarea-9_69e7877b9d53c-label\" class=\"forminator-label\">Echocardiography<\/label><textarea name=\"textarea-9\" placeholder=\"\" id=\"forminator-field-textarea-9_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-8\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-8_69e7877b9d53c\" id=\"forminator-field-textarea-8_69e7877b9d53c-label\" class=\"forminator-label\">Metabolic Screening<\/label><textarea name=\"textarea-8\" placeholder=\"\" id=\"forminator-field-textarea-8_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-7\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-7_69e7877b9d53c\" id=\"forminator-field-textarea-7_69e7877b9d53c-label\" class=\"forminator-label\">Hearing Test<\/label><textarea name=\"textarea-7\" placeholder=\"\" id=\"forminator-field-textarea-7_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-5\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-5_69e7877b9d53c\" id=\"forminator-field-textarea-5_69e7877b9d53c-label\" class=\"forminator-label\">USG<\/label><textarea name=\"textarea-5\" placeholder=\"\" id=\"forminator-field-textarea-5_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-4\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-4_69e7877b9d53c\" id=\"forminator-field-textarea-4_69e7877b9d53c-label\" class=\"forminator-label\">Genetic Testing<\/label><textarea name=\"textarea-4\" placeholder=\"\" id=\"forminator-field-textarea-4_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-3\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-3_69e7877b9d53c\" id=\"forminator-field-textarea-3_69e7877b9d53c-label\" class=\"forminator-label\">Other Tests<\/label><textarea name=\"textarea-3\" placeholder=\"\" id=\"forminator-field-textarea-3_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row forminator-action-buttons\"><div class=\"forminator-col forminator-col-12\"><input type=\"button\" value=\"Add item\" class=\"forminator-repeater-action-button forminator-repeater-add\" \/><input type=\"button\" value=\"Remove item\" class=\"forminator-repeater-action-button forminator-repeater-remove\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-2073--page-3\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2073--page-3-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"3\"\n\t\t\t\tdata-label=\"Page  3\"\n\t\t\t\tdata-actual-label=\"Page 4\"\n\t\t\t\tdata-name=\"page-break-4\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"group-4\" class=\"forminator-field-group forminator-col forminator-col-12 \"><label class=\"forminator-label forminator-repeater-label\">Physical Examination<\/label><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:true,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_69e7877b9d53c\" id=\"forminator-field-name-3_69e7877b9d53c-label\" class=\"forminator-label\">Height<\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"Cm\" id=\"forminator-field-name-3_69e7877b9d53c\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"name-6\" class=\"forminator-field-name forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-6_69e7877b9d53c\" id=\"forminator-field-name-6_69e7877b9d53c-label\" class=\"forminator-label\">\/ BW:<\/label><input type=\"text\" name=\"name-6\" value=\"\" placeholder=\"p\" id=\"forminator-field-name-6_69e7877b9d53c\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-4_69e7877b9d53c\" id=\"forminator-field-name-4_69e7877b9d53c-label\" class=\"forminator-label\">Kg<\/label><input type=\"text\" name=\"name-4\" value=\"\" placeholder=\"Kg\" id=\"forminator-field-name-4_69e7877b9d53c\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"name-5\" class=\"forminator-field-name forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-5_69e7877b9d53c\" id=\"forminator-field-name-5_69e7877b9d53c-label\" class=\"forminator-label\">\/ HC<\/label><input type=\"text\" name=\"name-5\" value=\"\" placeholder=\"p\" id=\"forminator-field-name-5_69e7877b9d53c\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-7\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-7_69e7877b9d53c\" id=\"forminator-field-name-7_69e7877b9d53c-label\" class=\"forminator-label\">\/ cm<\/label><input type=\"text\" name=\"name-7\" value=\"\" placeholder=\"p\" id=\"forminator-field-name-7_69e7877b9d53c\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"name-8\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-8_69e7877b9d53c\" id=\"forminator-field-name-8_69e7877b9d53c-label\" class=\"forminator-label\">\/ Overarm<\/label><input type=\"text\" name=\"name-8\" value=\"\" placeholder=\"p\" id=\"forminator-field-name-8_69e7877b9d53c\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"name-9\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-9_69e7877b9d53c\" id=\"forminator-field-name-9_69e7877b9d53c-label\" class=\"forminator-label\">Upper\/Lower<\/label><input type=\"text\" name=\"name-9\" value=\"\" placeholder=\"cm\" id=\"forminator-field-name-9_69e7877b9d53c\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-11\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-11_69e7877b9d53c\" id=\"forminator-field-textarea-11_69e7877b9d53c-label\" class=\"forminator-label\">Dysmorphic<\/label><textarea name=\"textarea-11\" placeholder=\"\" id=\"forminator-field-textarea-11_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-12\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-12_69e7877b9d53c\" id=\"forminator-field-textarea-12_69e7877b9d53c-label\" class=\"forminator-label\">Neurological<\/label><textarea name=\"textarea-12\" placeholder=\"\" id=\"forminator-field-textarea-12_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-13\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-13_69e7877b9d53c\" id=\"forminator-field-textarea-13_69e7877b9d53c-label\" class=\"forminator-label\">Extremities<\/label><textarea name=\"textarea-13\" placeholder=\"\" id=\"forminator-field-textarea-13_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-14\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-14_69e7877b9d53c\" id=\"forminator-field-textarea-14_69e7877b9d53c-label\" class=\"forminator-label\">Genital<\/label><textarea name=\"textarea-14\" placeholder=\"\" id=\"forminator-field-textarea-14_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-15\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-15_69e7877b9d53c\" id=\"forminator-field-textarea-15_69e7877b9d53c-label\" class=\"forminator-label\">ADDITIONAL FINDINGS<\/label><textarea name=\"textarea-15\" placeholder=\"\" id=\"forminator-field-textarea-15_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row forminator-action-buttons\"><div class=\"forminator-col forminator-col-12\"><input type=\"button\" value=\"Add item\" class=\"forminator-repeater-action-button forminator-repeater-add\" \/><input type=\"button\" value=\"Remove item\" class=\"forminator-repeater-action-button forminator-repeater-remove\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-2073--page-4\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2073--page-4-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"4\"\n\t\t\t\tdata-label=\"Page  4\"\n\t\t\t\tdata-actual-label=\"Page 5\"\n\t\t\t\tdata-name=\"page-break-5\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"group-5\" class=\"forminator-field-group forminator-col forminator-col-12 \"><label class=\"forminator-label forminator-repeater-label\">Family History<\/label><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:true,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"textarea-16\" class=\"forminator-field-textarea forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-16_69e7877b9d53c\" id=\"forminator-field-textarea-16_69e7877b9d53c-label\" class=\"forminator-label\">Mother&#039;s Name Surname<\/label><textarea name=\"textarea-16\" placeholder=\"\" id=\"forminator-field-textarea-16_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><div id=\"textarea-17\" class=\"forminator-field-textarea forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-17_69e7877b9d53c\" id=\"forminator-field-textarea-17_69e7877b9d53c-label\" class=\"forminator-label\">Mother&#039;s ID No<\/label><textarea name=\"textarea-17\" placeholder=\"\" id=\"forminator-field-textarea-17_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><div id=\"date-4\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-picker_69e7877b9d53c\" id=\"forminator-field-date-4-picker_69e7877b9d53c-label\" class=\"forminator-label\">Mother&#039;s Date of Birth<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-4\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-4-picker_69e7877b9d53c\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-18\" class=\"forminator-field-textarea forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-18_69e7877b9d53c\" id=\"forminator-field-textarea-18_69e7877b9d53c-label\" class=\"forminator-label\">Father&#039;s Name Surname<\/label><textarea name=\"textarea-18\" placeholder=\"\" id=\"forminator-field-textarea-18_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><div id=\"textarea-19\" class=\"forminator-field-textarea forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-19_69e7877b9d53c\" id=\"forminator-field-textarea-19_69e7877b9d53c-label\" class=\"forminator-label\">Father&#039;s ID No<\/label><textarea name=\"textarea-19\" placeholder=\"\" id=\"forminator-field-textarea-19_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><div id=\"date-5\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-5-picker_69e7877b9d53c\" id=\"forminator-field-date-5-picker_69e7877b9d53c-label\" class=\"forminator-label\">Father&#039;s Date of Birth<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-5\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-5-picker_69e7877b9d53c\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-20\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-20_69e7877b9d53c\" id=\"forminator-field-textarea-20_69e7877b9d53c-label\" class=\"forminator-label\">Number of MR Individuals in the Family<\/label><textarea name=\"textarea-20\" placeholder=\"\" id=\"forminator-field-textarea-20_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-21\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-21_69e7877b9d53c\" id=\"forminator-field-textarea-21_69e7877b9d53c-label\" class=\"forminator-label\">Known Hereditary Disease in the Fa<\/label><textarea name=\"textarea-21\" placeholder=\"\" id=\"forminator-field-textarea-21_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-22\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-22_69e7877b9d53c\" id=\"forminator-field-textarea-22_69e7877b9d53c-label\" class=\"forminator-label\">G1<\/label><textarea name=\"textarea-22\" placeholder=\"\" id=\"forminator-field-textarea-22_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><div id=\"textarea-23\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-23_69e7877b9d53c\" id=\"forminator-field-textarea-23_69e7877b9d53c-label\" class=\"forminator-label\">G2<\/label><textarea name=\"textarea-23\" placeholder=\"\" id=\"forminator-field-textarea-23_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-24\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-24_69e7877b9d53c\" id=\"forminator-field-textarea-24_69e7877b9d53c-label\" class=\"forminator-label\">G3<\/label><textarea name=\"textarea-24\" placeholder=\"\" id=\"forminator-field-textarea-24_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><div id=\"textarea-25\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-25_69e7877b9d53c\" id=\"forminator-field-textarea-25_69e7877b9d53c-label\" class=\"forminator-label\">G4<\/label><textarea name=\"textarea-25\" placeholder=\"\" id=\"forminator-field-textarea-25_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-26\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-26_69e7877b9d53c\" id=\"forminator-field-textarea-26_69e7877b9d53c-label\" class=\"forminator-label\">G5<\/label><textarea name=\"textarea-26\" placeholder=\"\" id=\"forminator-field-textarea-26_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><div id=\"textarea-27\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-27_69e7877b9d53c\" id=\"forminator-field-textarea-27_69e7877b9d53c-label\" class=\"forminator-label\">G6<\/label><textarea name=\"textarea-27\" placeholder=\"\" id=\"forminator-field-textarea-27_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row forminator-action-buttons\"><div class=\"forminator-col forminator-col-12\"><input type=\"button\" value=\"Add item\" class=\"forminator-repeater-action-button forminator-repeater-add\" \/><input type=\"button\" value=\"Remove item\" class=\"forminator-repeater-action-button forminator-repeater-remove\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-2073--page-5\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2073--page-5-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"5\"\n\t\t\t\tdata-label=\"Page  5\"\n\t\t\t\tdata-actual-label=\"Page 6\"\n\t\t\t\tdata-name=\"page-break-7\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"group-6\" class=\"forminator-field-group forminator-col forminator-col-12 \"><label class=\"forminator-label forminator-repeater-label\">Family Tree<\/label><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:true,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2073__field--select-2_69e7877b9d53c\" id=\"forminator-form-2073__field--select-2_69e7877b9d53c-label\" class=\"forminator-label\">Origin of Mother<\/label><select  id=\"forminator-form-2073__field--select-2_69e7877b9d53c\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-2\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Origin of Mother\" data-search=\"false\" data-search-placeholder=\"Origin of Mother\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2073__field--select-2_69e7877b9d53c-label\"><option value=\"\"  >Origin of Mother<\/option><option value=\"European (Non-Hispanic\/White)\"  data-calculation=\"0\">European (Non-Hispanic\/White)<\/option><option value=\"African \/ African American\"  data-calculation=\"0\">African \/ African American<\/option><option value=\"East Asian\"  data-calculation=\"0\">East Asian<\/option><option value=\"South Asian\"  data-calculation=\"0\">South Asian<\/option><option value=\"Hispanic or Latino\"  data-calculation=\"0\">Hispanic or Latino<\/option><option value=\"Middle Eastern \/ North African\"  data-calculation=\"0\">Middle Eastern \/ North African<\/option><option value=\"Native American \/ Alaskan Native\"  data-calculation=\"0\">Native American \/ Alaskan Native<\/option><option value=\"Other \/ Mixed Ancestry\"  data-calculation=\"0\">Other \/ Mixed Ancestry<\/option><option value=\"Unknown \/ Prefer not to answer\"  data-calculation=\"0\">Unknown \/ Prefer not to answer<\/option><\/select><\/div><\/div><div id=\"name-10\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-10_69e7877b9d53c\" id=\"forminator-field-name-10_69e7877b9d53c-label\" class=\"forminator-label\">Origin of Mother<\/label><input type=\"text\" name=\"name-10\" value=\"\" placeholder=\"\" id=\"forminator-field-name-10_69e7877b9d53c\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-3\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2073__field--select-3_69e7877b9d53c\" id=\"forminator-form-2073__field--select-3_69e7877b9d53c-label\" class=\"forminator-label\">Origin of Father<\/label><select  id=\"forminator-form-2073__field--select-3_69e7877b9d53c\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-3\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Origin of Father\" data-search=\"false\" data-search-placeholder=\"Origin of Father\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2073__field--select-3_69e7877b9d53c-label\"><option value=\"\"  >Origin of Father<\/option><option value=\"European (Non-Hispanic\/White)\"  data-calculation=\"0\">European (Non-Hispanic\/White)<\/option><option value=\"African \/ African American\"  data-calculation=\"0\">African \/ African American<\/option><option value=\"East Asian\"  data-calculation=\"0\">East Asian<\/option><option value=\"South Asian\"  data-calculation=\"0\">South Asian<\/option><option value=\"Hispanic or Latino\"  data-calculation=\"0\">Hispanic or Latino<\/option><option value=\"Middle Eastern \/ North African\"  data-calculation=\"0\">Middle Eastern \/ North African<\/option><option value=\"Native American \/ Alaskan Native\"  data-calculation=\"0\">Native American \/ Alaskan Native<\/option><option value=\"Other \/ Mixed Ancestry\"  data-calculation=\"0\">Other \/ Mixed Ancestry<\/option><option value=\"Unknown \/ Prefer not to answer\"  data-calculation=\"0\">Unknown \/ Prefer not to answer<\/option><\/select><\/div><\/div><div id=\"name-11\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-11_69e7877b9d53c\" id=\"forminator-field-name-11_69e7877b9d53c-label\" class=\"forminator-label\">Origin of Father<\/label><input type=\"text\" name=\"name-11\" value=\"\" placeholder=\"\" id=\"forminator-field-name-11_69e7877b9d53c\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-2-69e7877b9d53c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-69e7877b9d53c-label\" class=\"forminator-label\">Control<\/span><label id=\"forminator-field-checkbox-2-1-69e7877b9d53c-label\" for=\"forminator-field-checkbox-2-1-69e7877b9d53c\" class=\"forminator-checkbox\" title=\"Photograph\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"one\" id=\"forminator-field-checkbox-2-1-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-2-1-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Photograph<\/span><\/label><label id=\"forminator-field-checkbox-2-2-69e7877b9d53c-label\" for=\"forminator-field-checkbox-2-2-69e7877b9d53c\" class=\"forminator-checkbox\" title=\"Consent Form\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"two\" id=\"forminator-field-checkbox-2-2-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-2-2-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Consent Form<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-3\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-3-69e7877b9d53c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-3-69e7877b9d53c-label\" class=\"forminator-label\">Material Type<\/span><label id=\"forminator-field-checkbox-3-1-69e7877b9d53c-label\" for=\"forminator-field-checkbox-3-1-69e7877b9d53c\" class=\"forminator-checkbox\" title=\"Peripheral Blood\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"one\" id=\"forminator-field-checkbox-3-1-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-3-1-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Peripheral Blood<\/span><\/label><label id=\"forminator-field-checkbox-3-2-69e7877b9d53c-label\" for=\"forminator-field-checkbox-3-2-69e7877b9d53c\" class=\"forminator-checkbox\" title=\"Amniotic Fluid\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"two\" id=\"forminator-field-checkbox-3-2-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-3-2-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Amniotic Fluid<\/span><\/label><label id=\"forminator-field-checkbox-3-3-69e7877b9d53c-label\" for=\"forminator-field-checkbox-3-3-69e7877b9d53c\" class=\"forminator-checkbox\" title=\"CVS\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"CVS\" id=\"forminator-field-checkbox-3-3-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-3-3-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">CVS<\/span><\/label><label id=\"forminator-field-checkbox-3-4-69e7877b9d53c-label\" for=\"forminator-field-checkbox-3-4-69e7877b9d53c\" class=\"forminator-checkbox\" title=\"Cord Blood\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Cord-Blood\" id=\"forminator-field-checkbox-3-4-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-3-4-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cord Blood<\/span><\/label><label id=\"forminator-field-checkbox-3-5-69e7877b9d53c-label\" for=\"forminator-field-checkbox-3-5-69e7877b9d53c\" class=\"forminator-checkbox\" title=\"Saliva\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Saliva\" id=\"forminator-field-checkbox-3-5-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-3-5-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Saliva<\/span><\/label><label id=\"forminator-field-checkbox-3-6-69e7877b9d53c-label\" for=\"forminator-field-checkbox-3-6-69e7877b9d53c\" class=\"forminator-checkbox\" title=\"Skin Biopsy\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Skin-Biopsy\" id=\"forminator-field-checkbox-3-6-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-3-6-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Skin Biopsy<\/span><\/label><label id=\"forminator-field-checkbox-3-7-69e7877b9d53c-label\" for=\"forminator-field-checkbox-3-7-69e7877b9d53c\" class=\"forminator-checkbox\" title=\"FTA Card\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"FTA-Card\" id=\"forminator-field-checkbox-3-7-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-3-7-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">FTA Card<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-28\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-28_69e7877b9d53c\" id=\"forminator-field-textarea-28_69e7877b9d53c-label\" class=\"forminator-label\">Findings<\/label><textarea name=\"textarea-28\" placeholder=\"\" id=\"forminator-field-textarea-28_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-29\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-29_69e7877b9d53c\" id=\"forminator-field-textarea-29_69e7877b9d53c-label\" class=\"forminator-label\">Requested Test \/ Plan<\/label><textarea name=\"textarea-29\" placeholder=\"\" id=\"forminator-field-textarea-29_69e7877b9d53c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row forminator-action-buttons\"><div class=\"forminator-col forminator-col-12\"><input type=\"button\" value=\"Add item\" class=\"forminator-repeater-action-button forminator-repeater-add\" \/><input type=\"button\" value=\"Remove item\" class=\"forminator-repeater-action-button forminator-repeater-remove\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-2073--page-6\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2073--page-6-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"6\"\n\t\t\t\tdata-label=\"Page  6\"\n\t\t\t\tdata-actual-label=\"Page 7\"\n\t\t\t\tdata-name=\"page-break-6\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Consent Form<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-4\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-4-69e7877b9d53c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-4-69e7877b9d53c-label\" class=\"forminator-label\">Definition and Purpose of Whole Exome Sequencing (WES), Clinical Exome Sequencing (CES) and Panel Testing Whole Exome Sequencing (WES) involves extracting the DNA sequence of approximately 180,000 exons, which are parts of the approximately 20,000 genes found in the human genome. Clinical Exome Sequencing (CES) is a process that sequences about only 5,000 genes in the human genome that have been proven to cause diseases. Panel Sequencing focuses on sequencing specific groups of genes associated with a patient&#039;s indication. The number of genes in these panels varies depending on the clinical condition. In WES, CES, and panel tests, the DNA sequence obtained using Next Generation Sequencing technology is compared with the reference human genome. The molecular genetic changes that are suspected to be the cause of a disease through informatics analyses are evaluated. Mitochondrial DNA (mtDNA) is a double-stranded structure that is 16,569 base pairs long and contains 37 genes, and is located in an organelle other than the nucleus in the cell. MtDNA is inherited from the mother. Mitochondrial diseases show clinical and genetic heterogeneity due to homoplasmy and heteroplasmy. Only point mutation analysis is performed in the mitochondrial DNA disease panel.<\/span><label id=\"forminator-field-checkbox-4-1-69e7877b9d53c-label\" for=\"forminator-field-checkbox-4-1-69e7877b9d53c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Accept\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"one\" id=\"forminator-field-checkbox-4-1-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-4-1-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I Accept<\/span><\/label><label id=\"forminator-field-checkbox-4-2-69e7877b9d53c-label\" for=\"forminator-field-checkbox-4-2-69e7877b9d53c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Decline\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"two\" id=\"forminator-field-checkbox-4-2-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-4-2-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I Decline<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-2073--page-7\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2073--page-7-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"7\"\n\t\t\t\tdata-label=\"Page  7\"\n\t\t\t\tdata-actual-label=\"Page 8\"\n\t\t\t\tdata-name=\"page-break-8\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"checkbox-5\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-5-69e7877b9d53c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-5-69e7877b9d53c-label\" class=\"forminator-label\">The whole process of testing is specific to the genetic situation of interest and does not give information about the whole genetic structure of the individual. The Whole Exome Sequencing Test cannot analyze all exons in the human genome because of various technical reasons. This test does not guarantee that the test takers, other family members and\/or children to be born will be completely healthy. Other genetic or non-genetic diseases cannot be excluded in cases where the test results cannot explain the disease-forming change and are interpreted as normal. The accuracy of this test can be influenced by previous bone marrow transplantation, recent blood infusion, or other therapies that may add external DNA to the blood sample. The DNA used in this test is extracted from the blood instead of germ cells, and therefore there is a possibility of a change in outcomes due to chimerism (at least two different sets of DNA) , which may rarely be observed. While this test can detect point mutation and small deletion\/duplications (&lt;20bp) at exon and exon-intron junctions, it cannot detect changes in unexamined regions (regulator, promoter, deep intronic, etc.), major deletions\/duplications and complex rearrangements, balanced translocations, repetitive sequence regions, copy number changes, mosaicism, mitochondrial DNA mutations, epigenetic changes such as methylation disorders. The coverage and reading depths at the exon-intron junction may vary. Almost all of the bioinformatic analyzes of this DNA-based test are based on foreignbased databases, and in most of these diseases, there are few or no defined mutation profiles and\/or polymorphic characteristics for the population of our country. In the test reports, Pathogenic, Likely Pathogenic, or Uncertain Significance Variants, variants that are considered to be related to the phenotype according to the ACMG (American College of Medical Genetics and Genomics) criteria are listed. Additionally, Variants of Uncertain Significance (VUS) are further classified as &quot;Strong Variants of Uncertain Significance&quot; and &quot;Weak Variants of Uncertain Significance.&quot; Variants that may potentially be proven to cause disease with additional studies are classified as &quot;Strong Variants of Uncertain Clinical Significance.&quot; While Strong Uncertain Significance Variants are reported, Weak Uncertain Significance Variants are not. These variants should be evaluated with current data in terms of their association with the disease being tested. A variant whose pathogenesis is not understood at the time of the report and not listed in the report can be classified as pathogenic by scientific studies over time. Rare polymorphisms may lead to false positive\/ negative. Therefore, the positive\/negative results should be evaluated by the physician in accordance with the clinical findings and if necessary, confirmed by other diagnostic methods.<\/span><label id=\"forminator-field-checkbox-5-1-69e7877b9d53c-label\" for=\"forminator-field-checkbox-5-1-69e7877b9d53c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Accept\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"one\" id=\"forminator-field-checkbox-5-1-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-5-1-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I Accept<\/span><\/label><label id=\"forminator-field-checkbox-5-2-69e7877b9d53c-label\" for=\"forminator-field-checkbox-5-2-69e7877b9d53c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Decline\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"two\" id=\"forminator-field-checkbox-5-2-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-5-2-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I Decline<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-2073--page-8\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2073--page-8-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"8\"\n\t\t\t\tdata-label=\"Page  8\"\n\t\t\t\tdata-actual-label=\"Page 9\"\n\t\t\t\tdata-name=\"page-break-9\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"checkbox-6\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-6-69e7877b9d53c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-6-69e7877b9d53c-label\" class=\"forminator-label\">To perform these tests a blood sample of at least 2ml at EDTA tube should be taken from the individual undergoing the test. This blood sample is usually taken from the veins of the arm. In cases where the sample is insufficient, or the acquired DNA is at a level that cannot be analyzed, the sample can be requested again and the test can be repeated. In addition, additional testing can be recommended for the mother, father and other family members in the presence of any suspicious findings after first analyses or when a genetic carrier analysis is required.<\/span><label id=\"forminator-field-checkbox-6-1-69e7877b9d53c-label\" for=\"forminator-field-checkbox-6-1-69e7877b9d53c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Accept\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"one\" id=\"forminator-field-checkbox-6-1-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-6-1-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I Accept<\/span><\/label><label id=\"forminator-field-checkbox-6-2-69e7877b9d53c-label\" for=\"forminator-field-checkbox-6-2-69e7877b9d53c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Decline\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"two\" id=\"forminator-field-checkbox-6-2-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-6-2-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I Decline<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-7\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-7-69e7877b9d53c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-7-69e7877b9d53c-label\" class=\"forminator-label\">Results The turnaround time for this tests may vary due to technical or analytical factors. It is appropriate to give results with genetic counseling. All genetic data are personel; results will only be shared with the signatory person(s) and the signatory physician. Genetic test results also have findings for family members. If it is found that it carries a mutation\/variant in any of the genes analyzed, it may be necessary to test only those mutations\/variants with the DNA from the blood taken from the mother and father to determine the clinical significance of these mutations\/variants. For this reason, the consents of the parents are taken in this consent form. These results may also cause effects for other family members. This situation should be discussed with the clinician; there may be different opinions about the management options among health service providers, these results cannot be shared with other family members without permission. Genoks Genetics Center is not responsible for any anxiety or psychological problems that may arise during the test or from knowing the results. Genoks Genetics Center may use the remaining blood sample and data for research purposes with personal information concealed to explore biological mechanisms that may contribute to a better understanding of diseases.<\/span><label id=\"forminator-field-checkbox-7-1-69e7877b9d53c-label\" for=\"forminator-field-checkbox-7-1-69e7877b9d53c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Accept\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"one\" id=\"forminator-field-checkbox-7-1-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-7-1-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I Accept<\/span><\/label><label id=\"forminator-field-checkbox-7-2-69e7877b9d53c-label\" for=\"forminator-field-checkbox-7-2-69e7877b9d53c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Decline\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"two\" id=\"forminator-field-checkbox-7-2-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-7-2-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I Decline<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-8\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-8-69e7877b9d53c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-8-69e7877b9d53c-label\" class=\"forminator-label\">In WES\/CES testing, the detection of variants in certain genes that are associated with predisposition to serious conditions such as cancer or heart disease, and listed in the ACMG guidelines, is defined as &quot;Secondary Findings,&quot; regardless of the indication. The reporting of these results is made according to the request of the person in the consent form. It should be kept in mind that these results may pose a risk to other family members. Genoks Genetics Center is not responsible for the psychological conditions that these results may cause.<\/span><label id=\"forminator-field-checkbox-8-1-69e7877b9d53c-label\" for=\"forminator-field-checkbox-8-1-69e7877b9d53c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Accept\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"one\" id=\"forminator-field-checkbox-8-1-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-8-1-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I Accept<\/span><\/label><label id=\"forminator-field-checkbox-8-2-69e7877b9d53c-label\" for=\"forminator-field-checkbox-8-2-69e7877b9d53c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Decline\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"two\" id=\"forminator-field-checkbox-8-2-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-8-2-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I Decline<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-2073--page-9\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2073--page-9-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"9\"\n\t\t\t\tdata-label=\"Page  9\"\n\t\t\t\tdata-actual-label=\"Page 10\"\n\t\t\t\tdata-name=\"\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"checkbox-9\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-9-69e7877b9d53c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-9-69e7877b9d53c-label\" class=\"forminator-label\">The consent form must be obtained from the patient or a legally authorized parent\/caretaker to be able to perform this test. This form should also be signed by the physician and delivered to Genoks Genetics Center. 1) I have read the test information form for the genetic screening test applied to me or my child and received the necessary explanations. I saw, read and understood the written explanation of genetic analysis. Learned about genetic basis, probabilities, prevention and treatment of diseases tested. I received information about the risks that I might face during the test process and the limits of the test. I got answered all my questions and I know how much time I need to get the results. I have been informed about the person to contact in case of any questions or concerns. 2) I agree my test results to be shared with my signatory physician. Because of the complexity of DNA-based tests and the importance of test results, I agree that the outcomes will be reported through physicians and that I should contact with the physicians for test results. 3) By signing this form, I consent to Genoks Genetics Center for genetic testing with my blood sample. At any time without specifying the reason I can withdraw my approval completely or partially, and I have the right to not to know the test results. 4) I know that I can request the destruction of the test material with name and the results so far at any time. 5) I consent to the storage and use of unused test material in the laboratory for other genetic tests, provided that my personal information is confidential. 6) I consent to the storage and use of my test results in a statistical database for scientific purposes. I allow my data analyses to be used by Genoks Genetics Center in any report or publication by concealing my personal information. 7) I consent to Genoks to conduct genetic analysis of my blood sample either in its own laboratory or in a domestic or foreign laboratory if necessary.<\/span><label id=\"forminator-field-checkbox-9-1-69e7877b9d53c-label\" for=\"forminator-field-checkbox-9-1-69e7877b9d53c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Agree\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"one\" id=\"forminator-field-checkbox-9-1-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-9-1-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I Agree<\/span><\/label><label id=\"forminator-field-checkbox-9-2-69e7877b9d53c-label\" for=\"forminator-field-checkbox-9-2-69e7877b9d53c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Decline\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"two\" id=\"forminator-field-checkbox-9-2-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-9-2-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I Decline<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-10\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-10-69e7877b9d53c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-10-69e7877b9d53c-label\" class=\"forminator-label\">I consent to the reporting of Secondary Findings in genes listed in the ACMG secondary findings guidelines that are unrelated to my indication (Applicable only to patients undergoing WES\/CES).<\/span><label id=\"forminator-field-checkbox-10-1-69e7877b9d53c-label\" for=\"forminator-field-checkbox-10-1-69e7877b9d53c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Yes\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"one\" id=\"forminator-field-checkbox-10-1-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-10-1-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Yes<\/span><\/label><label id=\"forminator-field-checkbox-10-2-69e7877b9d53c-label\" for=\"forminator-field-checkbox-10-2-69e7877b9d53c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"No\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"two\" id=\"forminator-field-checkbox-10-2-69e7877b9d53c\" aria-labelledby=\"forminator-field-checkbox-10-2-69e7877b9d53c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">No<\/span><\/label><\/div><\/div><\/div><\/div><button class=\"forminator-button forminator-pagination-submit\" style=\"display: none;\" disabled>Submit<\/button><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"ac3501e7a1\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/2074\" \/><input type=\"hidden\" name=\"form_id\" value=\"2073\"><input type=\"hidden\" name=\"page_id\" value=\"2074\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/genoks.com.tr\/en\/wes-ces-panel-patient-information-and-consent-form\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-2074","page","type-page","status-publish","hentry"],"aioseo_notices":[],"aioseo_head":"\n\t\t<!-- All in One SEO Pro 4.9.5.2 - 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