{"id":2138,"date":"2026-01-04T16:53:55","date_gmt":"2026-01-04T16:53:55","guid":{"rendered":"https:\/\/genoks.com.tr\/?page_id=2138"},"modified":"2026-01-04T16:57:17","modified_gmt":"2026-01-04T16:57:17","slug":"genetic-test-request-consent","status":"publish","type":"page","link":"https:\/\/genoks.com.tr\/en\/genetic-test-request-consent\/","title":{"rendered":"Genetic Test Request &amp; Consent"},"content":{"rendered":"\n<p>Please select the relevant genetic test or consent form from the list below. Once a selection is made, the corresponding form will be displayed automatically.\n\nKindly ensure that all information is completed accurately and that the consent sections are reviewed carefully before submission. These forms are required to proceed with genetic testing and related laboratory procedures.<\/p>\n<p>&nbsp;<\/p>\n<div class=\"gx-form-switcher\">\n  <label for=\"gxFormSelect\"><strong>Select Form<\/strong><\/label>\n  <select id=\"gxFormSelect\">\n    <option value=\"\">\u2014 Select \u2014<\/option>\n    <option value=\"f-2073\">WES\/CES\/PANEL Patient Information and Consent Form<\/option>\n    <option value=\"f-2133\">WGS consent<\/option>\n    <option value=\"f-2134\">Molecular Cytogenetic Tests Consent Form<\/option>\n    <option value=\"f-2135\">Hematology and Oncological Test Request Form<\/option>\n    <option value=\"f-2136\">Huntington Disease Consent Form<\/option>\n    <option value=\"f-2137\">Prenatal Diagnosis Consent Form<\/option>\n  <\/select>\n<\/div>\n\n<div class=\"gx-forms\">\n  <div id=\"f-2073\" class=\"gx-form\">\n    <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=\"6a659396d470c\"><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=\"6a659396d470c\"\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_6a659396d470c\" id=\"forminator-field-date-3-picker_6a659396d470c-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_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-name-1_6a659396d470c-label\" class=\"forminator-label\">Name<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-phone-1_6a659396d470c-label\" class=\"forminator-label\">ID No<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-date-1-picker_6a659396d470c-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_6a659396d470c\" 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-1-6a659396d470c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-6a659396d470c-label\" class=\"forminator-label\">Gender<\/span><label id=\"forminator-field-checkbox-1-1-6a659396d470c-label\" for=\"forminator-field-checkbox-1-1-6a659396d470c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Male\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-1-1-6a659396d470c-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-1-2-6a659396d470c-label\" for=\"forminator-field-checkbox-1-2-6a659396d470c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Female\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"two\" id=\"forminator-field-checkbox-1-2-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-1-2-6a659396d470c-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_6a659396d470c\" id=\"forminator-form-2073__field--select-1_6a659396d470c-label\" class=\"forminator-label\">Sampling Location<\/label><select  id=\"forminator-form-2073__field--select-1_6a659396d470c\" 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_6a659396d470c-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_6a659396d470c\" id=\"forminator-field-email-1_6a659396d470c-label\" class=\"forminator-label\">Email Address<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-phone-2_6a659396d470c-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-address-1-street_address_6a659396d470c-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-address-1-address_line_6a659396d470c-label\" class=\"forminator-label\">Apartment, suite, etc<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-address-1-city_6a659396d470c-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"\" id=\"forminator-field-address-1-city_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-address-1-state_6a659396d470c-label\" class=\"forminator-label\">State\/Province<\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"\" id=\"forminator-field-address-1-state_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-address-1-zip_6a659396d470c-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"\" id=\"forminator-field-address-1-zip_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-2073__field--address-1-country_6a659396d470c-label\" class=\"forminator-label\">Country<\/label><select name=\"address-1-country\" id=\"forminator-field-2073__field--address-1-country_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-name-2_6a659396d470c-label\" class=\"forminator-label\">Name<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-email-2_6a659396d470c-label\" class=\"forminator-label\">Email Address<\/label><input type=\"email\" name=\"email-2\" value=\"\" placeholder=\"\" id=\"forminator-field-email-2_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-phone-3_6a659396d470c-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-3\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-3_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-address-2-street_address_6a659396d470c-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-2-street_address\" placeholder=\"\" id=\"forminator-field-address-2-street_address_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-address-2-address_line_6a659396d470c-label\" class=\"forminator-label\">Apartment, suite, etc<\/label><input type=\"text\" name=\"address-2-address_line\" placeholder=\"\" id=\"forminator-field-address-2-address_line_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-address-2-city_6a659396d470c-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-2-city\" placeholder=\"\" id=\"forminator-field-address-2-city_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-address-2-state_6a659396d470c-label\" class=\"forminator-label\">State\/Province<\/label><input type=\"text\" name=\"address-2-state\" placeholder=\"\" id=\"forminator-field-address-2-state_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-address-2-zip_6a659396d470c-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-2-zip\" placeholder=\"\" id=\"forminator-field-address-2-zip_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-2073__field--address-2-country_6a659396d470c-label\" class=\"forminator-label\">Country<\/label><select name=\"address-2-country\" id=\"forminator-field-2073__field--address-2-country_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-url-1_6a659396d470c-label\" class=\"forminator-label\">Website<\/label><input type=\"url\" name=\"url-1\" value=\"\" placeholder=\"\" id=\"forminator-field-url-1_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-1_6a659396d470c-label\" class=\"forminator-label\">Physician\u2019s Notes<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-2_6a659396d470c-label\" class=\"forminator-label\">Complication<\/label><textarea name=\"textarea-2\" placeholder=\"\" id=\"forminator-field-textarea-2_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-6_6a659396d470c-label\" class=\"forminator-label\">MRI<\/label><textarea name=\"textarea-6\" placeholder=\"\" id=\"forminator-field-textarea-6_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-10_6a659396d470c-label\" class=\"forminator-label\">Eye Examination<\/label><textarea name=\"textarea-10\" placeholder=\"\" id=\"forminator-field-textarea-10_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-9_6a659396d470c-label\" class=\"forminator-label\">Echocardiography<\/label><textarea name=\"textarea-9\" placeholder=\"\" id=\"forminator-field-textarea-9_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-8_6a659396d470c-label\" class=\"forminator-label\">Metabolic Screening<\/label><textarea name=\"textarea-8\" placeholder=\"\" id=\"forminator-field-textarea-8_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-7_6a659396d470c-label\" class=\"forminator-label\">Hearing Test<\/label><textarea name=\"textarea-7\" placeholder=\"\" id=\"forminator-field-textarea-7_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-5_6a659396d470c-label\" class=\"forminator-label\">USG<\/label><textarea name=\"textarea-5\" placeholder=\"\" id=\"forminator-field-textarea-5_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-4_6a659396d470c-label\" class=\"forminator-label\">Genetic Testing<\/label><textarea name=\"textarea-4\" placeholder=\"\" id=\"forminator-field-textarea-4_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-3_6a659396d470c-label\" class=\"forminator-label\">Other Tests<\/label><textarea name=\"textarea-3\" placeholder=\"\" id=\"forminator-field-textarea-3_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-name-3_6a659396d470c-label\" class=\"forminator-label\">Height<\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"Cm\" id=\"forminator-field-name-3_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-name-6_6a659396d470c-label\" class=\"forminator-label\">\/ BW:<\/label><input type=\"text\" name=\"name-6\" value=\"\" placeholder=\"p\" id=\"forminator-field-name-6_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-name-4_6a659396d470c-label\" class=\"forminator-label\">Kg<\/label><input type=\"text\" name=\"name-4\" value=\"\" placeholder=\"Kg\" id=\"forminator-field-name-4_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-name-5_6a659396d470c-label\" class=\"forminator-label\">\/ HC<\/label><input type=\"text\" name=\"name-5\" value=\"\" placeholder=\"p\" id=\"forminator-field-name-5_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-name-7_6a659396d470c-label\" class=\"forminator-label\">\/ cm<\/label><input type=\"text\" name=\"name-7\" value=\"\" placeholder=\"p\" id=\"forminator-field-name-7_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-name-8_6a659396d470c-label\" class=\"forminator-label\">\/ Overarm<\/label><input type=\"text\" name=\"name-8\" value=\"\" placeholder=\"p\" id=\"forminator-field-name-8_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-name-9_6a659396d470c-label\" class=\"forminator-label\">Upper\/Lower<\/label><input type=\"text\" name=\"name-9\" value=\"\" placeholder=\"cm\" id=\"forminator-field-name-9_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-11_6a659396d470c-label\" class=\"forminator-label\">Dysmorphic<\/label><textarea name=\"textarea-11\" placeholder=\"\" id=\"forminator-field-textarea-11_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-12_6a659396d470c-label\" class=\"forminator-label\">Neurological<\/label><textarea name=\"textarea-12\" placeholder=\"\" id=\"forminator-field-textarea-12_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-13_6a659396d470c-label\" class=\"forminator-label\">Extremities<\/label><textarea name=\"textarea-13\" placeholder=\"\" id=\"forminator-field-textarea-13_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-14_6a659396d470c-label\" class=\"forminator-label\">Genital<\/label><textarea name=\"textarea-14\" placeholder=\"\" id=\"forminator-field-textarea-14_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-15_6a659396d470c-label\" class=\"forminator-label\">ADDITIONAL FINDINGS<\/label><textarea name=\"textarea-15\" placeholder=\"\" id=\"forminator-field-textarea-15_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-16_6a659396d470c-label\" class=\"forminator-label\">Mother&#039;s Name Surname<\/label><textarea name=\"textarea-16\" placeholder=\"\" id=\"forminator-field-textarea-16_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-17_6a659396d470c-label\" class=\"forminator-label\">Mother&#039;s ID No<\/label><textarea name=\"textarea-17\" placeholder=\"\" id=\"forminator-field-textarea-17_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-date-4-picker_6a659396d470c-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_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-18_6a659396d470c-label\" class=\"forminator-label\">Father&#039;s Name Surname<\/label><textarea name=\"textarea-18\" placeholder=\"\" id=\"forminator-field-textarea-18_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-19_6a659396d470c-label\" class=\"forminator-label\">Father&#039;s ID No<\/label><textarea name=\"textarea-19\" placeholder=\"\" id=\"forminator-field-textarea-19_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-date-5-picker_6a659396d470c-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_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-20_6a659396d470c-label\" class=\"forminator-label\">Number of MR Individuals in the Family<\/label><textarea name=\"textarea-20\" placeholder=\"\" id=\"forminator-field-textarea-20_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-21_6a659396d470c-label\" class=\"forminator-label\">Known Hereditary Disease in the Fa<\/label><textarea name=\"textarea-21\" placeholder=\"\" id=\"forminator-field-textarea-21_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-22_6a659396d470c-label\" class=\"forminator-label\">G1<\/label><textarea name=\"textarea-22\" placeholder=\"\" id=\"forminator-field-textarea-22_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-23_6a659396d470c-label\" class=\"forminator-label\">G2<\/label><textarea name=\"textarea-23\" placeholder=\"\" id=\"forminator-field-textarea-23_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-24_6a659396d470c-label\" class=\"forminator-label\">G3<\/label><textarea name=\"textarea-24\" placeholder=\"\" id=\"forminator-field-textarea-24_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-25_6a659396d470c-label\" class=\"forminator-label\">G4<\/label><textarea name=\"textarea-25\" placeholder=\"\" id=\"forminator-field-textarea-25_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-26_6a659396d470c-label\" class=\"forminator-label\">G5<\/label><textarea name=\"textarea-26\" placeholder=\"\" id=\"forminator-field-textarea-26_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-27_6a659396d470c-label\" class=\"forminator-label\">G6<\/label><textarea name=\"textarea-27\" placeholder=\"\" id=\"forminator-field-textarea-27_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-form-2073__field--select-2_6a659396d470c-label\" class=\"forminator-label\">Origin of Mother<\/label><select  id=\"forminator-form-2073__field--select-2_6a659396d470c\" 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_6a659396d470c-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_6a659396d470c\" id=\"forminator-field-name-10_6a659396d470c-label\" class=\"forminator-label\">Origin of Mother<\/label><input type=\"text\" name=\"name-10\" value=\"\" placeholder=\"\" id=\"forminator-field-name-10_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-form-2073__field--select-3_6a659396d470c-label\" class=\"forminator-label\">Origin of Father<\/label><select  id=\"forminator-form-2073__field--select-3_6a659396d470c\" 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_6a659396d470c-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_6a659396d470c\" id=\"forminator-field-name-11_6a659396d470c-label\" class=\"forminator-label\">Origin of Father<\/label><input type=\"text\" name=\"name-11\" value=\"\" placeholder=\"\" id=\"forminator-field-name-11_6a659396d470c\" 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-2-6a659396d470c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-6a659396d470c-label\" class=\"forminator-label\">Control<\/span><label id=\"forminator-field-checkbox-2-1-6a659396d470c-label\" for=\"forminator-field-checkbox-2-1-6a659396d470c\" class=\"forminator-checkbox\" title=\"Photograph\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"one\" id=\"forminator-field-checkbox-2-1-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-2-1-6a659396d470c-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-2-2-6a659396d470c-label\" for=\"forminator-field-checkbox-2-2-6a659396d470c\" class=\"forminator-checkbox\" title=\"Consent Form\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"two\" id=\"forminator-field-checkbox-2-2-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-2-2-6a659396d470c-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-3-6a659396d470c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-3-6a659396d470c-label\" class=\"forminator-label\">Material Type<\/span><label id=\"forminator-field-checkbox-3-1-6a659396d470c-label\" for=\"forminator-field-checkbox-3-1-6a659396d470c\" class=\"forminator-checkbox\" title=\"Peripheral Blood\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"one\" id=\"forminator-field-checkbox-3-1-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-3-1-6a659396d470c-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-3-2-6a659396d470c-label\" for=\"forminator-field-checkbox-3-2-6a659396d470c\" class=\"forminator-checkbox\" title=\"Amniotic Fluid\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"two\" id=\"forminator-field-checkbox-3-2-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-3-2-6a659396d470c-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-3-3-6a659396d470c-label\" for=\"forminator-field-checkbox-3-3-6a659396d470c\" class=\"forminator-checkbox\" title=\"CVS\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"CVS\" id=\"forminator-field-checkbox-3-3-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-3-3-6a659396d470c-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-3-4-6a659396d470c-label\" for=\"forminator-field-checkbox-3-4-6a659396d470c\" class=\"forminator-checkbox\" title=\"Cord Blood\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Cord-Blood\" id=\"forminator-field-checkbox-3-4-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-3-4-6a659396d470c-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-3-5-6a659396d470c-label\" for=\"forminator-field-checkbox-3-5-6a659396d470c\" class=\"forminator-checkbox\" title=\"Saliva\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Saliva\" id=\"forminator-field-checkbox-3-5-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-3-5-6a659396d470c-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-3-6-6a659396d470c-label\" for=\"forminator-field-checkbox-3-6-6a659396d470c\" class=\"forminator-checkbox\" title=\"Skin Biopsy\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Skin-Biopsy\" id=\"forminator-field-checkbox-3-6-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-3-6-6a659396d470c-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-3-7-6a659396d470c-label\" for=\"forminator-field-checkbox-3-7-6a659396d470c\" class=\"forminator-checkbox\" title=\"FTA Card\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"FTA-Card\" id=\"forminator-field-checkbox-3-7-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-3-7-6a659396d470c-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_6a659396d470c\" id=\"forminator-field-textarea-28_6a659396d470c-label\" class=\"forminator-label\">Findings<\/label><textarea name=\"textarea-28\" placeholder=\"\" id=\"forminator-field-textarea-28_6a659396d470c\" 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_6a659396d470c\" id=\"forminator-field-textarea-29_6a659396d470c-label\" class=\"forminator-label\">Requested Test \/ Plan<\/label><textarea name=\"textarea-29\" placeholder=\"\" id=\"forminator-field-textarea-29_6a659396d470c\" 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-4-6a659396d470c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-4-6a659396d470c-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-4-1-6a659396d470c-label\" for=\"forminator-field-checkbox-4-1-6a659396d470c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Accept\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"one\" id=\"forminator-field-checkbox-4-1-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-4-1-6a659396d470c-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-4-2-6a659396d470c-label\" for=\"forminator-field-checkbox-4-2-6a659396d470c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Decline\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"two\" id=\"forminator-field-checkbox-4-2-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-4-2-6a659396d470c-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-5-6a659396d470c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-5-6a659396d470c-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-5-1-6a659396d470c-label\" for=\"forminator-field-checkbox-5-1-6a659396d470c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Accept\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"one\" id=\"forminator-field-checkbox-5-1-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-5-1-6a659396d470c-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-5-2-6a659396d470c-label\" for=\"forminator-field-checkbox-5-2-6a659396d470c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Decline\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"two\" id=\"forminator-field-checkbox-5-2-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-5-2-6a659396d470c-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-6-6a659396d470c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-6-6a659396d470c-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-6-1-6a659396d470c-label\" for=\"forminator-field-checkbox-6-1-6a659396d470c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Accept\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"one\" id=\"forminator-field-checkbox-6-1-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-6-1-6a659396d470c-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-6-2-6a659396d470c-label\" for=\"forminator-field-checkbox-6-2-6a659396d470c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Decline\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"two\" id=\"forminator-field-checkbox-6-2-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-6-2-6a659396d470c-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-7-6a659396d470c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-7-6a659396d470c-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-7-1-6a659396d470c-label\" for=\"forminator-field-checkbox-7-1-6a659396d470c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Accept\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"one\" id=\"forminator-field-checkbox-7-1-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-7-1-6a659396d470c-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-7-2-6a659396d470c-label\" for=\"forminator-field-checkbox-7-2-6a659396d470c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Decline\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"two\" id=\"forminator-field-checkbox-7-2-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-7-2-6a659396d470c-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-8-6a659396d470c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-8-6a659396d470c-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-8-1-6a659396d470c-label\" for=\"forminator-field-checkbox-8-1-6a659396d470c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Accept\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"one\" id=\"forminator-field-checkbox-8-1-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-8-1-6a659396d470c-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-8-2-6a659396d470c-label\" for=\"forminator-field-checkbox-8-2-6a659396d470c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Decline\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"two\" id=\"forminator-field-checkbox-8-2-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-8-2-6a659396d470c-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-9-6a659396d470c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-9-6a659396d470c-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-9-1-6a659396d470c-label\" for=\"forminator-field-checkbox-9-1-6a659396d470c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Agree\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"one\" id=\"forminator-field-checkbox-9-1-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-9-1-6a659396d470c-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-9-2-6a659396d470c-label\" for=\"forminator-field-checkbox-9-2-6a659396d470c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Decline\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"two\" id=\"forminator-field-checkbox-9-2-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-9-2-6a659396d470c-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-10-6a659396d470c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-10-6a659396d470c-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-10-1-6a659396d470c-label\" for=\"forminator-field-checkbox-10-1-6a659396d470c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Yes\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"one\" id=\"forminator-field-checkbox-10-1-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-10-1-6a659396d470c-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-10-2-6a659396d470c-label\" for=\"forminator-field-checkbox-10-2-6a659396d470c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"No\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"two\" id=\"forminator-field-checkbox-10-2-6a659396d470c\" aria-labelledby=\"forminator-field-checkbox-10-2-6a659396d470c-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=\"9aa12dfe7e\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/2138\" \/><input type=\"hidden\" name=\"form_id\" value=\"2073\"><input type=\"hidden\" name=\"page_id\" value=\"2138\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/genoks.com.tr\/en\/genetic-test-request-consent\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>\n  <\/div>\n\n  <div id=\"f-2133\" class=\"gx-form\">\n    <div class=\"forminator-ui forminator-custom-form forminator-custom-form-2133 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-2133\" data-uid=\"6a659396e67c2\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-2133\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-2133 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=\"2133\"\n\t\t\t\tenctype=\"multipart\/form-data\" data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6a659396e67c2\"\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-2133--page-0\"\n\t\t\t\tclass=\"forminator-pagination forminator-pagination-start\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2133--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=\"section-patient\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Patient Information<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-patient\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-patient_6a659396e67c2\" id=\"forminator-field-name-patient_6a659396e67c2-label\" class=\"forminator-label\">Name Surname <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-patient\" value=\"\" placeholder=\"\" id=\"forminator-field-name-patient_6a659396e67c2\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-id\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-id_6a659396e67c2\" id=\"forminator-field-text-id_6a659396e67c2-label\" class=\"forminator-label\">ID Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-id\" value=\"\" placeholder=\"\" id=\"forminator-field-text-id_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-dob\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-dob-picker_6a659396e67c2\" id=\"forminator-field-date-dob-picker_6a659396e67c2-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-dob\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-dob-picker_6a659396e67c2\" 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=\"radio-gender\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-gender-6a659396e67c2-label\"><span id=\"forminator-radiogroup-radio-gender-6a659396e67c2-label\" class=\"forminator-label\">Gender <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-gender-label-1\" for=\"forminator-field-radio-gender-1-6a659396e67c2\" class=\"forminator-radio forminator-radio-inline\" title=\"Female\"><input type=\"radio\" name=\"radio-gender\" value=\"Female\" id=\"forminator-field-radio-gender-1-6a659396e67c2\" aria-labelledby=\"forminator-field-radio-gender-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Female<\/span><\/label><label id=\"forminator-field-radio-gender-label-2\" for=\"forminator-field-radio-gender-2-6a659396e67c2\" class=\"forminator-radio forminator-radio-inline\" title=\"Male\"><input type=\"radio\" name=\"radio-gender\" value=\"Male\" id=\"forminator-field-radio-gender-2-6a659396e67c2\" aria-labelledby=\"forminator-field-radio-gender-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Male<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-sampling\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-sampling-picker_6a659396e67c2\" id=\"forminator-field-date-sampling-picker_6a659396e67c2-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-sampling\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-sampling-picker_6a659396e67c2\" 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=\"email-patient\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-patient_6a659396e67c2\" id=\"forminator-field-email-patient_6a659396e67c2-label\" class=\"forminator-label\">E-mail<\/label><input type=\"email\" name=\"email-patient\" value=\"\" placeholder=\"\" id=\"forminator-field-email-patient_6a659396e67c2\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-patient\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-patient_6a659396e67c2\" id=\"forminator-field-phone-patient_6a659396e67c2-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-patient\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-patient_6a659396e67c2\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-patient\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-patient-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-patient-street_address_6a659396e67c2\" id=\"forminator-field-address-patient-street_address_6a659396e67c2-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-patient-street_address\" placeholder=\"\" id=\"forminator-field-address-patient-street_address_6a659396e67c2\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-patient-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-patient-address_line_6a659396e67c2\" id=\"forminator-field-address-patient-address_line_6a659396e67c2-label\" class=\"forminator-label\">Apartment, suite, etc<\/label><input type=\"text\" name=\"address-patient-address_line\" placeholder=\"\" id=\"forminator-field-address-patient-address_line_6a659396e67c2\" 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-patient-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-patient-city_6a659396e67c2\" id=\"forminator-field-address-patient-city_6a659396e67c2-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-patient-city\" placeholder=\"\" id=\"forminator-field-address-patient-city_6a659396e67c2\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><div id=\"address-patient-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-patient-state_6a659396e67c2\" id=\"forminator-field-address-patient-state_6a659396e67c2-label\" class=\"forminator-label\">State\/Province<\/label><input type=\"text\" name=\"address-patient-state\" placeholder=\"\" id=\"forminator-field-address-patient-state_6a659396e67c2\" 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-patient-zip\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-patient-zip_6a659396e67c2\" id=\"forminator-field-address-patient-zip_6a659396e67c2-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-patient-zip\" placeholder=\"\" id=\"forminator-field-address-patient-zip_6a659396e67c2\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><div id=\"address-patient-country\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-2133__field--address-patient-country_6a659396e67c2\" id=\"forminator-field-2133__field--address-patient-country_6a659396e67c2-label\" class=\"forminator-label\">Country<\/label><select name=\"address-patient-country\" id=\"forminator-field-2133__field--address-patient-country_6a659396e67c2\" 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><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-2133--page-1\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2133--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=\"section-phys\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Physician Information<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-phys\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-phys_6a659396e67c2\" id=\"forminator-field-name-phys_6a659396e67c2-label\" class=\"forminator-label\">Physician Name Surname<\/label><input type=\"text\" name=\"name-phys\" value=\"\" placeholder=\"\" id=\"forminator-field-name-phys_6a659396e67c2\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-phys-contact\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-phys-contact_6a659396e67c2\" id=\"forminator-field-text-phys-contact_6a659396e67c2-label\" class=\"forminator-label\">E-mail \/ Phone<\/label><input type=\"text\" name=\"text-phys-contact\" value=\"\" placeholder=\"\" id=\"forminator-field-text-phys-contact_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/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-2133--page-2\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2133--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=\"section-family\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Family History<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-mother-name\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-mother-name_6a659396e67c2\" id=\"forminator-field-text-mother-name_6a659396e67c2-label\" class=\"forminator-label\">Mother Name Surname<\/label><input type=\"text\" name=\"text-mother-name\" value=\"\" placeholder=\"\" id=\"forminator-field-text-mother-name_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-mother-id\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-mother-id_6a659396e67c2\" id=\"forminator-field-text-mother-id_6a659396e67c2-label\" class=\"forminator-label\">Mother ID Number<\/label><input type=\"text\" name=\"text-mother-id\" value=\"\" placeholder=\"\" id=\"forminator-field-text-mother-id_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-mother-dob\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-mother-dob-picker_6a659396e67c2\" id=\"forminator-field-date-mother-dob-picker_6a659396e67c2-label\" class=\"forminator-label\">Mother\u2019s 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-mother-dob\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-mother-dob-picker_6a659396e67c2\" 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=\"text-father-name\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-father-name_6a659396e67c2\" id=\"forminator-field-text-father-name_6a659396e67c2-label\" class=\"forminator-label\">Father Name Surname<\/label><input type=\"text\" name=\"text-father-name\" value=\"\" placeholder=\"\" id=\"forminator-field-text-father-name_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-father-id\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-father-id_6a659396e67c2\" id=\"forminator-field-text-father-id_6a659396e67c2-label\" class=\"forminator-label\">Father ID Number<\/label><input type=\"text\" name=\"text-father-id\" value=\"\" placeholder=\"\" id=\"forminator-field-text-father-id_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-father-dob\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-father-dob-picker_6a659396e67c2\" id=\"forminator-field-date-father-dob-picker_6a659396e67c2-label\" class=\"forminator-label\">Father\u2019s 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-father-dob\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-father-dob-picker_6a659396e67c2\" 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=\"text-mr-count\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-mr-count_6a659396e67c2\" id=\"forminator-field-text-mr-count_6a659396e67c2-label\" class=\"forminator-label\">Number of MR Individuals<\/label><input type=\"text\" name=\"text-mr-count\" value=\"\" placeholder=\"\" id=\"forminator-field-text-mr-count_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-known-disease\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-known-disease_6a659396e67c2\" id=\"forminator-field-text-known-disease_6a659396e67c2-label\" class=\"forminator-label\">Known Hereditary Disease<\/label><input type=\"text\" name=\"text-known-disease\" value=\"\" placeholder=\"\" id=\"forminator-field-text-known-disease_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-g1\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-g1_6a659396e67c2\" id=\"forminator-field-text-g1_6a659396e67c2-label\" class=\"forminator-label\">G1<\/label><input type=\"text\" name=\"text-g1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-g1_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-g2\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-g2_6a659396e67c2\" id=\"forminator-field-text-g2_6a659396e67c2-label\" class=\"forminator-label\">G2<\/label><input type=\"text\" name=\"text-g2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-g2_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-g3\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-g3_6a659396e67c2\" id=\"forminator-field-text-g3_6a659396e67c2-label\" class=\"forminator-label\">G3<\/label><input type=\"text\" name=\"text-g3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-g3_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-g4\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-g4_6a659396e67c2\" id=\"forminator-field-text-g4_6a659396e67c2-label\" class=\"forminator-label\">G4<\/label><input type=\"text\" name=\"text-g4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-g4_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-g5\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-g5_6a659396e67c2\" id=\"forminator-field-text-g5_6a659396e67c2-label\" class=\"forminator-label\">G5<\/label><input type=\"text\" name=\"text-g5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-g5_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-g6\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-g6_6a659396e67c2\" id=\"forminator-field-text-g6_6a659396e67c2-label\" class=\"forminator-label\">G6<\/label><input type=\"text\" name=\"text-g6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-g6_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/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-2133--page-3\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2133--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=\"section-phys-exam\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Physical Examination<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-height\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-height_6a659396e67c2\" id=\"forminator-field-text-height_6a659396e67c2-label\" class=\"forminator-label\">Height (cm)<\/label><input type=\"text\" name=\"text-height\" value=\"\" placeholder=\"\" id=\"forminator-field-text-height_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-height-p\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-height-p_6a659396e67c2\" id=\"forminator-field-text-height-p_6a659396e67c2-label\" class=\"forminator-label\">Height (p)<\/label><input type=\"text\" name=\"text-height-p\" value=\"\" placeholder=\"\" id=\"forminator-field-text-height-p_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-bw-kg\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-bw-kg_6a659396e67c2\" id=\"forminator-field-text-bw-kg_6a659396e67c2-label\" class=\"forminator-label\">BW (kg)<\/label><input type=\"text\" name=\"text-bw-kg\" value=\"\" placeholder=\"\" id=\"forminator-field-text-bw-kg_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-bw-p\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-bw-p_6a659396e67c2\" id=\"forminator-field-text-bw-p_6a659396e67c2-label\" class=\"forminator-label\">BW (p)<\/label><input type=\"text\" name=\"text-bw-p\" value=\"\" placeholder=\"\" id=\"forminator-field-text-bw-p_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-hc-cm\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-hc-cm_6a659396e67c2\" id=\"forminator-field-text-hc-cm_6a659396e67c2-label\" class=\"forminator-label\">HC (cm)<\/label><input type=\"text\" name=\"text-hc-cm\" value=\"\" placeholder=\"\" id=\"forminator-field-text-hc-cm_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-hc-p\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-hc-p_6a659396e67c2\" id=\"forminator-field-text-hc-p_6a659396e67c2-label\" class=\"forminator-label\">HC (p)<\/label><input type=\"text\" name=\"text-hc-p\" value=\"\" placeholder=\"\" id=\"forminator-field-text-hc-p_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-overarm\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-overarm_6a659396e67c2\" id=\"forminator-field-text-overarm_6a659396e67c2-label\" class=\"forminator-label\">Overarm (cm)<\/label><input type=\"text\" name=\"text-overarm\" value=\"\" placeholder=\"\" id=\"forminator-field-text-overarm_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-upper-lower\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-upper-lower_6a659396e67c2\" id=\"forminator-field-text-upper-lower_6a659396e67c2-label\" class=\"forminator-label\">Upper \/ Lower<\/label><input type=\"text\" name=\"text-upper-lower\" value=\"\" placeholder=\"\" id=\"forminator-field-text-upper-lower_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-dysmorphic\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-dysmorphic_6a659396e67c2\" id=\"forminator-field-textarea-dysmorphic_6a659396e67c2-label\" class=\"forminator-label\">Dysmorphic<\/label><textarea name=\"textarea-dysmorphic\" placeholder=\"\" id=\"forminator-field-textarea-dysmorphic_6a659396e67c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-neurologic\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-neurologic_6a659396e67c2\" id=\"forminator-field-textarea-neurologic_6a659396e67c2-label\" class=\"forminator-label\">Neurologic<\/label><textarea name=\"textarea-neurologic\" placeholder=\"\" id=\"forminator-field-textarea-neurologic_6a659396e67c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-extremities\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-extremities_6a659396e67c2\" id=\"forminator-field-textarea-extremities_6a659396e67c2-label\" class=\"forminator-label\">Extremities<\/label><textarea name=\"textarea-extremities\" placeholder=\"\" id=\"forminator-field-textarea-extremities_6a659396e67c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-genital\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-genital_6a659396e67c2\" id=\"forminator-field-textarea-genital_6a659396e67c2-label\" class=\"forminator-label\">Genital<\/label><textarea name=\"textarea-genital\" placeholder=\"\" id=\"forminator-field-textarea-genital_6a659396e67c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-add-findings\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-add-findings_6a659396e67c2\" id=\"forminator-field-textarea-add-findings_6a659396e67c2-label\" class=\"forminator-label\">ADDITIONAL FINDINGS<\/label><textarea name=\"textarea-add-findings\" placeholder=\"\" id=\"forminator-field-textarea-add-findings_6a659396e67c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/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-2133--page-4\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2133--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-6\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-anam\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Anamnesis<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-complication\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-complication_6a659396e67c2\" id=\"forminator-field-textarea-complication_6a659396e67c2-label\" class=\"forminator-label\">Complication<\/label><textarea name=\"textarea-complication\" placeholder=\"\" id=\"forminator-field-textarea-complication_6a659396e67c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-mrg\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-mrg_6a659396e67c2\" id=\"forminator-field-textarea-mrg_6a659396e67c2-label\" class=\"forminator-label\">MRG<\/label><textarea name=\"textarea-mrg\" placeholder=\"\" id=\"forminator-field-textarea-mrg_6a659396e67c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-eye-examination\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-eye-examination_6a659396e67c2\" id=\"forminator-field-textarea-eye-examination_6a659396e67c2-label\" class=\"forminator-label\">Eye Examination<\/label><textarea name=\"textarea-eye-examination\" placeholder=\"\" id=\"forminator-field-textarea-eye-examination_6a659396e67c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-echo\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-echo_6a659396e67c2\" id=\"forminator-field-textarea-echo_6a659396e67c2-label\" class=\"forminator-label\">ECHO<\/label><textarea name=\"textarea-echo\" placeholder=\"\" id=\"forminator-field-textarea-echo_6a659396e67c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-metabolic-t\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-metabolic-t_6a659396e67c2\" id=\"forminator-field-textarea-metabolic-t_6a659396e67c2-label\" class=\"forminator-label\">Metabolic T.<\/label><textarea name=\"textarea-metabolic-t\" placeholder=\"\" id=\"forminator-field-textarea-metabolic-t_6a659396e67c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-hearing-screening\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-hearing-screening_6a659396e67c2\" id=\"forminator-field-textarea-hearing-screening_6a659396e67c2-label\" class=\"forminator-label\">Hearing Screening<\/label><textarea name=\"textarea-hearing-screening\" placeholder=\"\" id=\"forminator-field-textarea-hearing-screening_6a659396e67c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-usg\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-usg_6a659396e67c2\" id=\"forminator-field-textarea-usg_6a659396e67c2-label\" class=\"forminator-label\">USG<\/label><textarea name=\"textarea-usg\" placeholder=\"\" id=\"forminator-field-textarea-usg_6a659396e67c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-genetic-test\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-genetic-test_6a659396e67c2\" id=\"forminator-field-textarea-genetic-test_6a659396e67c2-label\" class=\"forminator-label\">Genetic Test<\/label><textarea name=\"textarea-genetic-test\" placeholder=\"\" id=\"forminator-field-textarea-genetic-test_6a659396e67c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-other-tests\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-other-tests_6a659396e67c2\" id=\"forminator-field-textarea-other-tests_6a659396e67c2-label\" class=\"forminator-label\">Other Tests<\/label><textarea name=\"textarea-other-tests\" placeholder=\"\" id=\"forminator-field-textarea-other-tests_6a659396e67c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-findings-plan\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-findings-plan_6a659396e67c2\" id=\"forminator-field-textarea-findings-plan_6a659396e67c2-label\" class=\"forminator-label\">Findings Plan (1-4)<\/label><textarea name=\"textarea-findings-plan\" placeholder=\"1-\n2-\n3-\n4-\" id=\"forminator-field-textarea-findings-plan_6a659396e67c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/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-2133--page-5\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2133--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=\"section-consent\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Whole Genome Sequencing Test - Patient Consent Form<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-consent-info\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-consent-info\"><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-consent\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-consent-6a659396e67c2-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-consent-6a659396e67c2-label\" class=\"forminator-label\">CONSENT Declaration <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-checkbox-consent-1-6a659396e67c2-label\" for=\"forminator-field-checkbox-consent-1-6a659396e67c2\" class=\"forminator-checkbox\" title=\"I have read and understood the Whole Genome Sequencing test information and I give my consent as stated below.\"><input type=\"checkbox\" name=\"checkbox-consent[]\" value=\"agree\" id=\"forminator-field-checkbox-consent-1-6a659396e67c2\" aria-labelledby=\"forminator-field-checkbox-consent-1-6a659396e67c2-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I have read and understood the Whole Genome Sequencing test information and I give my consent as stated below.<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-declaration\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-declaration\"><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-incidental\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-incidental-6a659396e67c2-label\"><span id=\"forminator-radiogroup-radio-incidental-6a659396e67c2-label\" class=\"forminator-label\">I consent to reporting of Incidental Findings found in the genes listed in the ACMG guideline. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-incidental-label-1\" for=\"forminator-field-radio-incidental-1-6a659396e67c2\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-incidental\" value=\"Yes\" id=\"forminator-field-radio-incidental-1-6a659396e67c2\" aria-labelledby=\"forminator-field-radio-incidental-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-incidental-label-2\" for=\"forminator-field-radio-incidental-2-6a659396e67c2\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-incidental\" value=\"No\" id=\"forminator-field-radio-incidental-2-6a659396e67c2\" aria-labelledby=\"forminator-field-radio-incidental-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-sign\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-sign-picker_6a659396e67c2\" id=\"forminator-field-date-sign-picker_6a659396e67c2-label\" class=\"forminator-label\">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-sign\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-sign-picker_6a659396e67c2\" 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=\"text-patient-signname\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-patient-signname_6a659396e67c2\" id=\"forminator-field-text-patient-signname_6a659396e67c2-label\" class=\"forminator-label\">Patient Name\/Surname <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-patient-signname\" value=\"\" placeholder=\"\" id=\"forminator-field-text-patient-signname_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-parent-signname\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-parent-signname_6a659396e67c2\" id=\"forminator-field-text-parent-signname_6a659396e67c2-label\" class=\"forminator-label\">Parents Name\/Surname<\/label><input type=\"text\" name=\"text-parent-signname\" value=\"\" placeholder=\"\" id=\"forminator-field-text-parent-signname_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-phys-signname\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-phys-signname_6a659396e67c2\" id=\"forminator-field-text-phys-signname_6a659396e67c2-label\" class=\"forminator-label\">Physician Name\/Surname<\/label><input type=\"text\" name=\"text-phys-signname\" value=\"\" placeholder=\"\" id=\"forminator-field-text-phys-signname_6a659396e67c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-signed-form\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-signed-form_6a659396e67c2\" id=\"forminator-field-upload-signed-form_6a659396e67c2-label\" class=\"forminator-label\">Upload Signed Consent Form (optional)<\/label><div class=\"forminator-file-upload \" data-element=\"upload-signed-form_6a659396e67c2\"><input type=\"file\" name=\"upload-signed-form\" id=\"forminator-field-upload-signed-form_6a659396e67c2\" class=\"forminator-input-file\" tabindex=\"-1\"><button id=\"forminator-field-upload-signed-form_6a659396e67c2_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-signed-form_6a659396e67c2\">Choose File<\/button><span data-empty-text=\"No file chosen\">No file chosen<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Delete uploaded file<\/span><\/button><\/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-2133--page-6\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2133--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-8\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"checkbox-NaN\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-NaN-6a659396e67c2-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-NaN-6a659396e67c2-label\" class=\"forminator-label\">With the Whole Genome Sequencing, the full DNA sequence of 3 billion bases is obtained by Next Generation Sequencing technology. This obtained DNA sequence is compared with the reference human genome for bioinformatic analysis and evaluated the molecular genetic changes that may be the cause of a suspected disease.<\/span><label id=\"forminator-field-checkbox-NaN-1-6a659396e67c2-label\" for=\"forminator-field-checkbox-NaN-1-6a659396e67c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Agree\"><input type=\"checkbox\" name=\"checkbox-NaN[]\" value=\"one\" id=\"forminator-field-checkbox-NaN-1-6a659396e67c2\" aria-labelledby=\"forminator-field-checkbox-NaN-1-6a659396e67c2-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-NaN-2-6a659396e67c2-label\" for=\"forminator-field-checkbox-NaN-2-6a659396e67c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I disagree\"><input type=\"checkbox\" name=\"checkbox-NaN[]\" value=\"two\" id=\"forminator-field-checkbox-NaN-2-6a659396e67c2\" aria-labelledby=\"forminator-field-checkbox-NaN-2-6a659396e67c2-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I disagree<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-NaN\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-NaN-6a659396e67c2-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-NaN-6a659396e67c2-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. This test does not guarantee that the test takers, other family members and\/or children to be born will be completely healthy. Genetic or non-genetic diseases cannot be excluded in cases where the test results can&#039;t 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. Therefore there is a possibility of a change in outcomes due to chimerism, which may rarely be observed. Genome sequencing can not detect balanced translocations, repetitive sequence regions, mosaicism, mitochondrial DNA mutations, epigenetic changes such as methylation disorders. Almost all of the bioinformatic analyzes of this DNA-based test are based on foreign-based 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. For these reasons, whole genome sequencing is not a diagnostic test alone. The whole genome sequencing reports lists Pathogenic, Likely Pathogenic or Uncertain Significance Variants that are thought to be related to the phenotype classified according to ACMG (American College of Medical Genetics and Genomics) criteria. 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-NaN-1-6a659396e67c2-label\" for=\"forminator-field-checkbox-NaN-1-6a659396e67c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Agree\"><input type=\"checkbox\" name=\"checkbox-NaN[]\" value=\"one\" id=\"forminator-field-checkbox-NaN-1-6a659396e67c2\" aria-labelledby=\"forminator-field-checkbox-NaN-1-6a659396e67c2-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-NaN-2-6a659396e67c2-label\" for=\"forminator-field-checkbox-NaN-2-6a659396e67c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I disagree\"><input type=\"checkbox\" name=\"checkbox-NaN[]\" value=\"two\" id=\"forminator-field-checkbox-NaN-2-6a659396e67c2\" aria-labelledby=\"forminator-field-checkbox-NaN-2-6a659396e67c2-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I disagree<\/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-2133--page-7\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2133--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-9\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"checkbox-NaN\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-NaN-6a659396e67c2-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-NaN-6a659396e67c2-label\" class=\"forminator-label\">For the whole genome sequencing test, a blood sample of at least 2 ml at EDTA tube should be taken. 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 can&#039;t be analyzed, the sample can be requested again and the test can be repeated. In addition, additional testing can be recommended from 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. If allowed, Genoks GDC (Genetic Diagnostic Center) may retain the remaining blood sample to investigate biological mechanisms that may lead to a better understanding of diseases. Unused test material is also an important reference for quality assurance in terms of genetic testing in the laboratory. Protected samples beyond the test period are stored confidentially and not personally traceable.<\/span><label id=\"forminator-field-checkbox-NaN-1-6a659396e67c2-label\" for=\"forminator-field-checkbox-NaN-1-6a659396e67c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Agree\"><input type=\"checkbox\" name=\"checkbox-NaN[]\" value=\"one\" id=\"forminator-field-checkbox-NaN-1-6a659396e67c2\" aria-labelledby=\"forminator-field-checkbox-NaN-1-6a659396e67c2-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-NaN-2-6a659396e67c2-label\" for=\"forminator-field-checkbox-NaN-2-6a659396e67c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I disagree\"><input type=\"checkbox\" name=\"checkbox-NaN[]\" value=\"two\" id=\"forminator-field-checkbox-NaN-2-6a659396e67c2\" aria-labelledby=\"forminator-field-checkbox-NaN-2-6a659396e67c2-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I disagree<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-NaN\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-NaN-6a659396e67c2-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-NaN-6a659396e67c2-label\" class=\"forminator-label\">The resulting duration of the whole genome sequencing test may vary due to technical or analysis factors. It is appropriate to give results with genetic counseling. All genetic data are personal; 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 can&#039;t be shared with other family members without permission. The Genoks GDC is not responsible for any anxiety or psychological problems that may arise during the test or from knowing the results.<\/span><label id=\"forminator-field-checkbox-NaN-1-6a659396e67c2-label\" for=\"forminator-field-checkbox-NaN-1-6a659396e67c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Agree\"><input type=\"checkbox\" name=\"checkbox-NaN[]\" value=\"one\" id=\"forminator-field-checkbox-NaN-1-6a659396e67c2\" aria-labelledby=\"forminator-field-checkbox-NaN-1-6a659396e67c2-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-NaN-2-6a659396e67c2-label\" for=\"forminator-field-checkbox-NaN-2-6a659396e67c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I disagree\"><input type=\"checkbox\" name=\"checkbox-NaN[]\" value=\"two\" id=\"forminator-field-checkbox-NaN-2-6a659396e67c2\" aria-labelledby=\"forminator-field-checkbox-NaN-2-6a659396e67c2-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I disagree<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-NaN\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-NaN-6a659396e67c2-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-NaN-6a659396e67c2-label\" class=\"forminator-label\">Incidental Findings &quot;The detection of some genes listed in the ACMG guideline and associated with predisposition to serious situations such as cancer and cardiovascular diseases, independent of the cause of the indication for all Genome sequence analysis, is often defined as \u2018Incidental Findings\u2019. 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 GDC is not responsible for the psychological conditions that these results may cause.&quot;<\/span><label id=\"forminator-field-checkbox-NaN-1-6a659396e67c2-label\" for=\"forminator-field-checkbox-NaN-1-6a659396e67c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Agree\"><input type=\"checkbox\" name=\"checkbox-NaN[]\" value=\"one\" id=\"forminator-field-checkbox-NaN-1-6a659396e67c2\" aria-labelledby=\"forminator-field-checkbox-NaN-1-6a659396e67c2-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-NaN-2-6a659396e67c2-label\" for=\"forminator-field-checkbox-NaN-2-6a659396e67c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I disagree\"><input type=\"checkbox\" name=\"checkbox-NaN[]\" value=\"two\" id=\"forminator-field-checkbox-NaN-2-6a659396e67c2\" aria-labelledby=\"forminator-field-checkbox-NaN-2-6a659396e67c2-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I disagree<\/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-2133--page-8\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2133--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-10\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"checkbox-NaN\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-NaN-6a659396e67c2-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-NaN-6a659396e67c2-label\" class=\"forminator-label\">CONSENT Declaration The consent form must be obtained from the patient or a legally authorized parent \/ caretaker to be able to perform the Whole Genome Sequencing test. This form should also be signed by the physician and delivered to Genoks GDC. 1) I have read the test information form for the applied genetic screening test 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 about the blood sample and the limits of the test. I got answered all my questions and I know how much time I need to get the result. 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 GDC for the Whole Genome Sequence test 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 GDC in any report or publication by concealing my personal information. 7) I consent to Genoks to conduct a genetic analysis of my blood sample in a laboratory in his own or, if necessary, in a laboratory abroad.<\/span><label id=\"forminator-field-checkbox-NaN-1-6a659396e67c2-label\" for=\"forminator-field-checkbox-NaN-1-6a659396e67c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Agree\"><input type=\"checkbox\" name=\"checkbox-NaN[]\" value=\"one\" id=\"forminator-field-checkbox-NaN-1-6a659396e67c2\" aria-labelledby=\"forminator-field-checkbox-NaN-1-6a659396e67c2-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-NaN-2-6a659396e67c2-label\" for=\"forminator-field-checkbox-NaN-2-6a659396e67c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I disagree\"><input type=\"checkbox\" name=\"checkbox-NaN[]\" value=\"two\" id=\"forminator-field-checkbox-NaN-2-6a659396e67c2\" aria-labelledby=\"forminator-field-checkbox-NaN-2-6a659396e67c2-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I disagree<\/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-2133--page-9\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2133--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=\"page-break-5\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"checkbox-NaN\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-NaN-6a659396e67c2-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-NaN-6a659396e67c2-label\" class=\"forminator-label\">I consent to reporting of Incidental Findings found in the genes listed in the ACMG guideline.<\/span><label id=\"forminator-field-checkbox-NaN-1-6a659396e67c2-label\" for=\"forminator-field-checkbox-NaN-1-6a659396e67c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Yes\"><input type=\"checkbox\" name=\"checkbox-NaN[]\" value=\"one\" id=\"forminator-field-checkbox-NaN-1-6a659396e67c2\" aria-labelledby=\"forminator-field-checkbox-NaN-1-6a659396e67c2-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-NaN-2-6a659396e67c2-label\" for=\"forminator-field-checkbox-NaN-2-6a659396e67c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"No\"><input type=\"checkbox\" name=\"checkbox-NaN[]\" value=\"two\" id=\"forminator-field-checkbox-NaN-2-6a659396e67c2\" aria-labelledby=\"forminator-field-checkbox-NaN-2-6a659396e67c2-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><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-2133--page-10\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2133--page-10-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"10\"\n\t\t\t\tdata-label=\"Page  10\"\n\t\t\t\tdata-actual-label=\"Page 11\"\n\t\t\t\tdata-name=\"\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><\/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=\"fd7dee2c2a\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/2138\" \/><input type=\"hidden\" name=\"form_id\" value=\"2133\"><input type=\"hidden\" name=\"page_id\" value=\"2138\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/genoks.com.tr\/en\/genetic-test-request-consent\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>\n  <\/div>\n\n  <div id=\"f-2134\" class=\"gx-form\">\n    <div class=\"forminator-ui forminator-custom-form forminator-custom-form-2134 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-2134\" data-uid=\"6a659396f38b6\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-2134\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-2134 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=\"2134\"\n\t\t\t\t data-color-option=\"default\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6a659396f38b6\"\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-2134--page-0\"\n\t\t\t\tclass=\"forminator-pagination forminator-pagination-start\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2134--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\">Patient Information<\/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-1\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6a659396f38b6\" id=\"forminator-field-date-1-picker_6a659396f38b6-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-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_6a659396f38b6\" 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_6a659396f38b6\" id=\"forminator-field-name-1_6a659396f38b6-label\" class=\"forminator-label\">Patient Name<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_6a659396f38b6\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6a659396f38b6\" id=\"forminator-field-text-1_6a659396f38b6-label\" class=\"forminator-label\">Patient ID No<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6a659396f38b6\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_6a659396f38b6\" id=\"forminator-field-date-2-picker_6a659396f38b6-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-2\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-2-picker_6a659396f38b6\" 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=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-form-2134__field--select-1_6a659396f38b6\" id=\"forminator-form-2134__field--select-1_6a659396f38b6-label\" class=\"forminator-label\">Gender<\/label><select  id=\"forminator-form-2134__field--select-1_6a659396f38b6\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-1\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Gender\" data-search=\"false\" data-search-placeholder=\"Gender\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2134__field--select-1_6a659396f38b6-label\"><option value=\"\"  >Gender<\/option><option value=\"Male\"  data-calculation=\"0\">Male<\/option><option value=\"Female\"  data-calculation=\"0\">Female<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a659396f38b6\" id=\"forminator-field-email-1_6a659396f38b6-label\" class=\"forminator-label\">Email Address<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a659396f38b6\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6a659396f38b6\" id=\"forminator-field-phone-1_6a659396f38b6-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6a659396f38b6\" 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_6a659396f38b6\" id=\"forminator-field-address-1-street_address_6a659396f38b6-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_6a659396f38b6\" 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_6a659396f38b6\" id=\"forminator-field-address-1-address_line_6a659396f38b6-label\" class=\"forminator-label\">Apartment, suite, etc<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_6a659396f38b6\" 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_6a659396f38b6\" id=\"forminator-field-address-1-city_6a659396f38b6-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"\" id=\"forminator-field-address-1-city_6a659396f38b6\" 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_6a659396f38b6\" id=\"forminator-field-address-1-state_6a659396f38b6-label\" class=\"forminator-label\">State\/Province<\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"\" id=\"forminator-field-address-1-state_6a659396f38b6\" 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_6a659396f38b6\" id=\"forminator-field-address-1-zip_6a659396f38b6-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"\" id=\"forminator-field-address-1-zip_6a659396f38b6\" 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-2134__field--address-1-country_6a659396f38b6\" id=\"forminator-field-2134__field--address-1-country_6a659396f38b6-label\" class=\"forminator-label\">Country<\/label><select name=\"address-1-country\" id=\"forminator-field-2134__field--address-1-country_6a659396f38b6\" 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-2134--page-1\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2134--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 Information<\/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-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_6a659396f38b6\" id=\"forminator-field-name-2_6a659396f38b6-label\" class=\"forminator-label\">Physician Name<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_6a659396f38b6\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-2\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-2_6a659396f38b6\" id=\"forminator-field-email-2_6a659396f38b6-label\" class=\"forminator-label\">Physician Email Address<\/label><input type=\"email\" name=\"email-2\" value=\"\" placeholder=\"\" id=\"forminator-field-email-2_6a659396f38b6\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_6a659396f38b6\" id=\"forminator-field-phone-2_6a659396f38b6-label\" class=\"forminator-label\">Physician Phone<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_6a659396f38b6\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/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_6a659396f38b6\" id=\"forminator-field-textarea-1_6a659396f38b6-label\" class=\"forminator-label\">Clinical Information \/ Notes<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_6a659396f38b6\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><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_6a659396f38b6\" id=\"forminator-field-textarea-2_6a659396f38b6-label\" class=\"forminator-label\">Requested Test \/ Plan<\/label><textarea name=\"textarea-2\" placeholder=\"\" id=\"forminator-field-textarea-2_6a659396f38b6\" 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-2134--page-2\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2134--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=\"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-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-6a659396f38b6-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-6a659396f38b6-label\" class=\"forminator-label\">the purpose of the test will not be reported due to ethical and legal rules. Additional studies requested by the physician are also subject to separate consent. Consent Declaration<\/span><label id=\"forminator-field-checkbox-1-1-6a659396f38b6-label\" for=\"forminator-field-checkbox-1-1-6a659396f38b6\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Agree\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"agree\" id=\"forminator-field-checkbox-1-1-6a659396f38b6\" aria-labelledby=\"forminator-field-checkbox-1-1-6a659396f38b6-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-1-2-6a659396f38b6-label\" for=\"forminator-field-checkbox-1-2-6a659396f38b6\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Disagree\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"disagree\" id=\"forminator-field-checkbox-1-2-6a659396f38b6\" aria-labelledby=\"forminator-field-checkbox-1-2-6a659396f38b6-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I Disagree<\/span><\/label><\/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-2-6a659396f38b6-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-6a659396f38b6-label\" class=\"forminator-label\">1) I have read the consent form or had it read to me. I fully understand the indications, purpose, characteristics, accuracy, and limitations of the genetic test applied to me and\/or my child. I have been informed about the risks associated with the test process and the limitations of the test. I have received answers to all my questions and know how long it will take for the results to be available. I have been informed about whom to contact if I have further questions or concerns regarding the test. I acknowledge that I have filled out all the information in this form correctly and that any incomplete or incorrect information is my responsibility. 2) I consent to sharing my test results with the physician whose signature is below. Due to the complexity of DNA-based tests and the importance of test results, I accept that my results will be reported through physicians and that I need to contact the physicians for the test results. 3) By signing this form, I give approval to Genoks Genetics Center to perform this test on my blood sample. I have been informed that I can withdraw my consent in whole or in part at any time without providing a reason and that I have the right not to know the test results. 4) I understand that I can request the destruction of the test material and the results obtained up to that point 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 remains confidential. 6) I consent to the storage and use of my test results in a statistical database for scientific purposes. I allow Genoks Genetics Center to use my data in any reports or publications, with my personal information kept confidential. 7) I give approval to Genoks Genetics Center to either perform the genetic test on my blood sample in their own laboratory or, if deemed necessary, have it performed in a domestic or international laboratory. Date: Patient&#039;s Name\/S urn ame: Mother&#039;s Name\/ S urname: Father&#039;s Name\/Surname: *Signa ture : ID No \/ Signature : ID No \/ Signature: *For individuals under 18 years of age, a guardian&#039;s signature is required. For the consent form to be valid and for the sample to be processed, it is mandatory to complete the signature . field in full. Dokman No: GNK.FR.154 Yrrlk Tarih i:14\/11\/2024 Revizyon No: 00 Revizyon Tarihi: 00\/00\/0000 Page No: 2\/2 Address: Emniyet Mah. Silahtar Cad. No:67 Yenimahalle \/ Ankara Tel: 0 312 229 78 59 \/ 444 8 732 Web: global.genoks.com.tr<\/span><label id=\"forminator-field-checkbox-2-1-6a659396f38b6-label\" for=\"forminator-field-checkbox-2-1-6a659396f38b6\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Agree\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"agree\" id=\"forminator-field-checkbox-2-1-6a659396f38b6\" aria-labelledby=\"forminator-field-checkbox-2-1-6a659396f38b6-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-2-2-6a659396f38b6-label\" for=\"forminator-field-checkbox-2-2-6a659396f38b6\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"I Disagree\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"disagree\" id=\"forminator-field-checkbox-2-2-6a659396f38b6\" aria-labelledby=\"forminator-field-checkbox-2-2-6a659396f38b6-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I Disagree<\/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-2134--page-3\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2134--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=\"\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Signatures<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6a659396f38b6\" id=\"forminator-field-text-2_6a659396f38b6-label\" class=\"forminator-label\">Patient \/ Legal Representative Name Surname<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_6a659396f38b6\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-picker_6a659396f38b6\" id=\"forminator-field-date-3-picker_6a659396f38b6-label\" class=\"forminator-label\">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_6a659396f38b6\" 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=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_6a659396f38b6\" id=\"forminator-field-text-3_6a659396f38b6-label\" class=\"forminator-label\">Physician Name Surname<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_6a659396f38b6\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-4\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-picker_6a659396f38b6\" id=\"forminator-field-date-4-picker_6a659396f38b6-label\" class=\"forminator-label\">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-4\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-4-picker_6a659396f38b6\" 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><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=\"86df06cd84\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/2138\" \/><input type=\"hidden\" name=\"form_id\" value=\"2134\"><input type=\"hidden\" name=\"page_id\" value=\"2138\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/genoks.com.tr\/en\/genetic-test-request-consent\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>\n  <\/div>\n\n  <div id=\"f-2135\" class=\"gx-form\">\n    <div class=\"forminator-ui forminator-custom-form forminator-custom-form-2135 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-2135\" data-uid=\"6a65939704f57\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-2135\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-2135 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=\"2135\"\n\t\t\t\t data-color-option=\"default\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6a65939704f57\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-2135--page-0\"\n\t\t\t\tclass=\"forminator-pagination forminator-pagination-start\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2135--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=\"section-patient\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Patient Information<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-patient\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-patient_6a65939704f57\" id=\"forminator-field-name-patient_6a65939704f57-label\" class=\"forminator-label\">Name Surname <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-patient\" value=\"\" placeholder=\"\" id=\"forminator-field-name-patient_6a65939704f57\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-id\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-id_6a65939704f57\" id=\"forminator-field-text-id_6a65939704f57-label\" class=\"forminator-label\">ID No <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-id\" value=\"\" placeholder=\"\" id=\"forminator-field-text-id_6a65939704f57\" class=\"forminator-input forminator-name--field\" data-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-dob\" class=\"forminator-field-date forminator-col forminator-col-12 \"><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-gender\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-gender-6a65939704f57-label\"><span id=\"forminator-radiogroup-radio-gender-6a65939704f57-label\" class=\"forminator-label\">Gender<\/span><label id=\"forminator-field-radio-gender-label-1\" for=\"forminator-field-radio-gender-1-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"Female\"><input type=\"radio\" name=\"radio-gender\" value=\"female\" id=\"forminator-field-radio-gender-1-6a65939704f57\" aria-labelledby=\"forminator-field-radio-gender-label-1\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Female<\/span><\/label><label id=\"forminator-field-radio-gender-label-2\" for=\"forminator-field-radio-gender-2-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"Male\"><input type=\"radio\" name=\"radio-gender\" value=\"male\" id=\"forminator-field-radio-gender-2-6a65939704f57\" aria-labelledby=\"forminator-field-radio-gender-label-2\" data-calculation=\"0\"  \/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Male<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email_6a65939704f57\" id=\"forminator-field-email_6a65939704f57-label\" class=\"forminator-label\">E-mail<\/label><input type=\"email\" name=\"email\" value=\"\" placeholder=\"\" id=\"forminator-field-email_6a65939704f57\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone_6a65939704f57\" id=\"forminator-field-phone_6a65939704f57-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone\" value=\"\" placeholder=\"\" id=\"forminator-field-phone_6a65939704f57\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address\" class=\"forminator-field-address forminator-col forminator-col-12 \"><\/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-2135--page-1\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2135--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=\"section-tests\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Test Options<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-8261\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-8261-6a65939704f57-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-8261-6a65939704f57-label\" class=\"forminator-label\">Select Test(s)<\/span><label id=\"forminator-field-checkbox-8261-1-6a65939704f57-label\" for=\"forminator-field-checkbox-8261-1-6a65939704f57\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Onkogenoks Oncology Panel\"><input type=\"checkbox\" name=\"checkbox-8261[]\" value=\"onkogenoks oncology panel\" id=\"forminator-field-checkbox-8261-1-6a65939704f57\" aria-labelledby=\"forminator-field-checkbox-8261-1-6a65939704f57-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Onkogenoks Oncology Panel<\/span><\/label><label id=\"forminator-field-checkbox-8261-2-6a65939704f57-label\" for=\"forminator-field-checkbox-8261-2-6a65939704f57\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Hemagenoks DNA Panel\"><input type=\"checkbox\" name=\"checkbox-8261[]\" value=\"hemagenoks dna panel\" id=\"forminator-field-checkbox-8261-2-6a65939704f57\" aria-labelledby=\"forminator-field-checkbox-8261-2-6a65939704f57-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Hemagenoks DNA Panel<\/span><\/label><label id=\"forminator-field-checkbox-8261-3-6a65939704f57-label\" for=\"forminator-field-checkbox-8261-3-6a65939704f57\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Hemagenoks RNA Panel\"><input type=\"checkbox\" name=\"checkbox-8261[]\" value=\"hemagenoks rna panel\" id=\"forminator-field-checkbox-8261-3-6a65939704f57\" aria-labelledby=\"forminator-field-checkbox-8261-3-6a65939704f57-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Hemagenoks RNA Panel<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-testtitle\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-testtitle_6a65939704f57\" id=\"forminator-field-text-testtitle_6a65939704f57-label\" class=\"forminator-label\">Requested Test Title<\/label><input type=\"text\" name=\"text-testtitle\" value=\"\" placeholder=\"\" id=\"forminator-field-text-testtitle_6a65939704f57\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-sample\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Sample Information<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-sampletype\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-sampletype_6a65939704f57\" id=\"forminator-field-text-sampletype_6a65939704f57-label\" class=\"forminator-label\">Tissue \/ Sample Type<\/label><input type=\"text\" name=\"text-sampletype\" value=\"\" placeholder=\"\" id=\"forminator-field-text-sampletype_6a65939704f57\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-quantity\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-quantity_6a65939704f57\" id=\"forminator-field-text-quantity_6a65939704f57-label\" class=\"forminator-label\">Sample Quantity<\/label><input type=\"text\" name=\"text-quantity\" value=\"\" placeholder=\"\" id=\"forminator-field-text-quantity_6a65939704f57\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-site\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-site_6a65939704f57\" id=\"forminator-field-text-site_6a65939704f57-label\" class=\"forminator-label\">Collection Site<\/label><input type=\"text\" name=\"text-site\" value=\"\" placeholder=\"\" id=\"forminator-field-text-site_6a65939704f57\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-collection\" class=\"forminator-field-date forminator-col forminator-col-12 \"><\/div><\/div><div class=\"forminator-row\"><div id=\"text-sampleid\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-sampleid_6a65939704f57\" id=\"forminator-field-text-sampleid_6a65939704f57-label\" class=\"forminator-label\">Sample ID<\/label><input type=\"text\" name=\"text-sampleid\" value=\"\" placeholder=\"\" id=\"forminator-field-text-sampleid_6a65939704f57\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-purity\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-purity_6a65939704f57\" id=\"forminator-field-text-purity_6a65939704f57-label\" class=\"forminator-label\">Tumor Purity<\/label><input type=\"text\" name=\"text-purity\" value=\"\" placeholder=\"\" id=\"forminator-field-text-purity_6a65939704f57\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/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-2135--page-2\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2135--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=\"section-disease\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Disease Related Information<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-clindiag\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-clindiag_6a65939704f57\" id=\"forminator-field-text-clindiag_6a65939704f57-label\" class=\"forminator-label\">Clinical Diagnosis<\/label><input type=\"text\" name=\"text-clindiag\" value=\"\" placeholder=\"\" id=\"forminator-field-text-clindiag_6a65939704f57\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-age\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-age_6a65939704f57\" id=\"forminator-field-text-age_6a65939704f57-label\" class=\"forminator-label\">Age at Diagnosis<\/label><input type=\"text\" name=\"text-age\" value=\"\" placeholder=\"\" id=\"forminator-field-text-age_6a65939704f57\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-history\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-history_6a65939704f57\" id=\"forminator-field-textarea-history_6a65939704f57-label\" class=\"forminator-label\">Clinical History<\/label><textarea name=\"textarea-history\" placeholder=\"\" id=\"forminator-field-textarea-history_6a65939704f57\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-path\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-path_6a65939704f57\" id=\"forminator-field-text-path_6a65939704f57-label\" class=\"forminator-label\">Pathological Diagnosis<\/label><input type=\"text\" name=\"text-path\" value=\"\" placeholder=\"\" id=\"forminator-field-text-path_6a65939704f57\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-stage\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-stage_6a65939704f57\" id=\"forminator-field-text-stage_6a65939704f57-label\" class=\"forminator-label\">Disease Stage<\/label><input type=\"text\" name=\"text-stage\" value=\"\" placeholder=\"\" id=\"forminator-field-text-stage_6a65939704f57\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-meta\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-meta_6a65939704f57\" id=\"forminator-field-text-meta_6a65939704f57-label\" class=\"forminator-label\">Metastasis \/ Relapse \/ Transformation<\/label><input type=\"text\" name=\"text-meta\" value=\"\" placeholder=\"\" id=\"forminator-field-text-meta_6a65939704f57\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/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-2135--page-3\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2135--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=\"checkbox-5833\" class=\"forminator-field-checkbox forminator-col forminator-col-6 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-5833-6a65939704f57-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-5833-6a65939704f57-label\" class=\"forminator-label\">Blood Transfusion Performed?<\/span><label id=\"forminator-field-checkbox-5833-1-6a65939704f57-label\" for=\"forminator-field-checkbox-5833-1-6a65939704f57\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"No\"><input type=\"checkbox\" name=\"checkbox-5833[]\" value=\"no\" id=\"forminator-field-checkbox-5833-1-6a65939704f57\" aria-labelledby=\"forminator-field-checkbox-5833-1-6a65939704f57-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">No<\/span><\/label><label id=\"forminator-field-checkbox-5833-2-6a65939704f57-label\" for=\"forminator-field-checkbox-5833-2-6a65939704f57\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Yes\"><input type=\"checkbox\" name=\"checkbox-5833[]\" value=\"yes\" id=\"forminator-field-checkbox-5833-2-6a65939704f57\" aria-labelledby=\"forminator-field-checkbox-5833-2-6a65939704f57-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Yes<\/span><\/label><\/div><\/div><div id=\"date-transfusion\" class=\"forminator-field-date forminator-col forminator-col-6 \"><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-9826\" class=\"forminator-field-checkbox forminator-col forminator-col-6 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-9826-6a65939704f57-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-9826-6a65939704f57-label\" class=\"forminator-label\">Bone Marrow Transplantation Performed?<\/span><label id=\"forminator-field-checkbox-9826-1-6a65939704f57-label\" for=\"forminator-field-checkbox-9826-1-6a65939704f57\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"No\"><input type=\"checkbox\" name=\"checkbox-9826[]\" value=\"no\" id=\"forminator-field-checkbox-9826-1-6a65939704f57\" aria-labelledby=\"forminator-field-checkbox-9826-1-6a65939704f57-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">No<\/span><\/label><label id=\"forminator-field-checkbox-9826-2-6a65939704f57-label\" for=\"forminator-field-checkbox-9826-2-6a65939704f57\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Yes\"><input type=\"checkbox\" name=\"checkbox-9826[]\" value=\"yes\" id=\"forminator-field-checkbox-9826-2-6a65939704f57\" aria-labelledby=\"forminator-field-checkbox-9826-2-6a65939704f57-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Yes<\/span><\/label><\/div><\/div><div id=\"date-bmt\" class=\"forminator-field-date forminator-col forminator-col-6 \"><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-2428\" class=\"forminator-field-checkbox forminator-col forminator-col-6 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-2428-6a65939704f57-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2428-6a65939704f57-label\" class=\"forminator-label\">Organ Transplantation Performed?<\/span><label id=\"forminator-field-checkbox-2428-1-6a65939704f57-label\" for=\"forminator-field-checkbox-2428-1-6a65939704f57\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"No\"><input type=\"checkbox\" name=\"checkbox-2428[]\" value=\"no\" id=\"forminator-field-checkbox-2428-1-6a65939704f57\" aria-labelledby=\"forminator-field-checkbox-2428-1-6a65939704f57-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">No<\/span><\/label><label id=\"forminator-field-checkbox-2428-2-6a65939704f57-label\" for=\"forminator-field-checkbox-2428-2-6a65939704f57\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Yes\"><input type=\"checkbox\" name=\"checkbox-2428[]\" value=\"yes\" id=\"forminator-field-checkbox-2428-2-6a65939704f57\" aria-labelledby=\"forminator-field-checkbox-2428-2-6a65939704f57-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Yes<\/span><\/label><\/div><\/div><div id=\"date-organ\" class=\"forminator-field-date forminator-col forminator-col-6 \"><\/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-2135--page-4\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2135--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-6\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"textarea-biomarkers\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-biomarkers_6a65939704f57\" id=\"forminator-field-textarea-biomarkers_6a65939704f57-label\" class=\"forminator-label\">Other Biomarkers<\/label><textarea name=\"textarea-biomarkers\" placeholder=\"\" id=\"forminator-field-textarea-biomarkers_6a65939704f57\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-othercancers\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-othercancers_6a65939704f57\" id=\"forminator-field-textarea-othercancers_6a65939704f57-label\" class=\"forminator-label\">Other Cancers<\/label><textarea name=\"textarea-othercancers\" placeholder=\"\" id=\"forminator-field-textarea-othercancers_6a65939704f57\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-otherdiseases\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-otherdiseases_6a65939704f57\" id=\"forminator-field-textarea-otherdiseases_6a65939704f57-label\" class=\"forminator-label\">Other Diseases<\/label><textarea name=\"textarea-otherdiseases\" placeholder=\"\" id=\"forminator-field-textarea-otherdiseases_6a65939704f57\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-family\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-family_6a65939704f57\" id=\"forminator-field-textarea-family_6a65939704f57-label\" class=\"forminator-label\">Family History of Cancer<\/label><textarea name=\"textarea-family\" placeholder=\"\" id=\"forminator-field-textarea-family_6a65939704f57\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-additional\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-additional_6a65939704f57\" id=\"forminator-field-textarea-additional_6a65939704f57-label\" class=\"forminator-label\">Additional Clinical Information<\/label><textarea name=\"textarea-additional\" placeholder=\"\" id=\"forminator-field-textarea-additional_6a65939704f57\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/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-2135--page-5\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2135--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=\"radio-NaN\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\"><span id=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\" class=\"forminator-label\">Cancer is a complex disease characterized by the accumulation of genetic alterations occurring in different genes, resulting in heterogeneous cell populations that differ from other cancers arising in other tissues and, in some cases, even within the same tissue. These distinct genetic alterations act as biomarkers that determine cancer biology, disease progression, and the most appropriate treatment strategies. This test is performed to detect cancer-specific genetic alterations that arise during cancer development in tumor tissue, metastatic tissue derived from the primary tumor, or in blood and other bodily fluids. Through this test, your physician may obtain information on how the cancer is likely to progress, how it should be treated, which drugs it may respond to, whether it may benefit from targeted therapies, determine the most appropriate treatment methods and drug or drug combinations for you, obtain precise information regarding your individualized treatment process, and select monitoring strategies that allow adjustment of the drug dosage or modification of the drug itself when necessary.<\/span><label id=\"forminator-field-radio-NaN-label-1\" for=\"forminator-field-radio-NaN-1-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I Agree\"><input type=\"radio\" name=\"radio-NaN\" value=\"one\" id=\"forminator-field-radio-NaN-1-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Agree<\/span><\/label><label id=\"forminator-field-radio-NaN-label-2\" for=\"forminator-field-radio-NaN-2-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I disagree\"><input type=\"radio\" name=\"radio-NaN\" value=\"two\" id=\"forminator-field-radio-NaN-2-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I disagree<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-NaN\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\"><span id=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\" class=\"forminator-label\">The clinical sample selected by your physician based on your condition will generally consist of tumor tissue obtained at the time of diagnosis, or, in cases of disease progression, newly emerged cancer or metastatic tissue known to contain tumor cells, or, if these are not accessible, approximately 10 cc of peripheral blood collected into a special tube (the dedicated tube provided to you within the sample kit) and delivered to the Genoks GHDM laboratories within 48 hours. When deemed necessary by your physician, clinical samples such as urine or cerebrospinal fluid may also be preferred for cancer genomic profiling.<\/span><label id=\"forminator-field-radio-NaN-label-1\" for=\"forminator-field-radio-NaN-1-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I Agree\"><input type=\"radio\" name=\"radio-NaN\" value=\"one\" id=\"forminator-field-radio-NaN-1-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Agree<\/span><\/label><label id=\"forminator-field-radio-NaN-label-2\" for=\"forminator-field-radio-NaN-2-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I disagree\"><input type=\"radio\" name=\"radio-NaN\" value=\"two\" id=\"forminator-field-radio-NaN-2-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I disagree<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-NaN\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\"><span id=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\" class=\"forminator-label\">This test is based on the principle of high-throughput and deep, sensitive sequencing of genes and gene products, RNA\/DNA molecules that play a role in the carcinogenesis process and whose genetic alterations have the potential to clinically affect the course of your disease, using next-generation sequencing technology, followed by bioinformatic analysis and clinical interpretation of the results. The test results are shared with your physician and with you in a format that allows easy access to all understandable and clinically relevant information.<\/span><label id=\"forminator-field-radio-NaN-label-1\" for=\"forminator-field-radio-NaN-1-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I Agree\"><input type=\"radio\" name=\"radio-NaN\" value=\"one\" id=\"forminator-field-radio-NaN-1-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Agree<\/span><\/label><label id=\"forminator-field-radio-NaN-label-2\" for=\"forminator-field-radio-NaN-2-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I disagree\"><input type=\"radio\" name=\"radio-NaN\" value=\"two\" id=\"forminator-field-radio-NaN-2-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I disagree<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-NaN\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\"><span id=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\" class=\"forminator-label\">This test includes genes deemed appropriate for analysis by your physician in relation to your clinical condition. Upon request, the list of genes included within the scope of the test will be provided to you. 2. As a result of the test, a genetic alteration may not necessarily be identified, or a genetic alteration with no known clinical significance (Variant of Uncertain Significance, VUS) may be detected. 3. In addition to somatic alterations that arise during cancer development, inherited (maternally or paternally transmitted) and clinically significant genetic alterations may also be identified as a result of this test. Whether these genetic alterations are reported to you depends on your consent (see Scope of Consent). 4. This test is designed to assess DNA\/RNA-level alterations in cancer cells using cancer-related samples such as peripheral blood, bone marrow, and formalin-fixed paraffin-embedded tissue. It may not yield the expected results when performed on clinical materials outside .these sources, such as urine or cerebrospinal fluid. 5. In some cases, DNA\/RNA isolation of the expected quality may not be achieved due to pre-analytical processes or transport conditions. In such cases, a new sample may be requested.<\/span><label id=\"forminator-field-radio-NaN-label-1\" for=\"forminator-field-radio-NaN-1-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I Agree\"><input type=\"radio\" name=\"radio-NaN\" value=\"one\" id=\"forminator-field-radio-NaN-1-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Agree<\/span><\/label><label id=\"forminator-field-radio-NaN-label-2\" for=\"forminator-field-radio-NaN-2-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I Disagree\"><input type=\"radio\" name=\"radio-NaN\" value=\"two\" id=\"forminator-field-radio-NaN-2-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Disagree<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-NaN\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\"><span id=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\" class=\"forminator-label\">I have been informed in detail about the reason for performing the cancer genomic profiling test requested by my physician, as well as its possible results and limitations. I have read (or have had read to me) this document and have understood it. 2. I have read and understood that the results of this test will not be shared with anyone other than myself and the requesting physician.<\/span><label id=\"forminator-field-radio-NaN-label-1\" for=\"forminator-field-radio-NaN-1-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I Agree\"><input type=\"radio\" name=\"radio-NaN\" value=\"one\" id=\"forminator-field-radio-NaN-1-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Agree<\/span><\/label><label id=\"forminator-field-radio-NaN-label-2\" for=\"forminator-field-radio-NaN-2-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I Disagree\"><input type=\"radio\" name=\"radio-NaN\" value=\"two\" id=\"forminator-field-radio-NaN-2-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Disagree<\/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-2135--page-6\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2135--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-5\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"radio-NaN\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\"><span id=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\" class=\"forminator-label\">to the inclusion of hereditary genetic information identified as a result of this test in the report and to its disclosure to me accompanied by genetic counseling.<\/span><label id=\"forminator-field-radio-NaN-label-1\" for=\"forminator-field-radio-NaN-1-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I Agree\"><input type=\"radio\" name=\"radio-NaN\" value=\"one\" id=\"forminator-field-radio-NaN-1-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Agree<\/span><\/label><label id=\"forminator-field-radio-NaN-label-2\" for=\"forminator-field-radio-NaN-2-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I Disagree\"><input type=\"radio\" name=\"radio-NaN\" value=\"two\" id=\"forminator-field-radio-NaN-2-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Disagree<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-NaN\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\"><span id=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\" class=\"forminator-label\">to the use of the genetic information and results obtained from this test for research purposes and in publications, provided that my identity is anonymized and cannot be traced to my personal identification information.<\/span><label id=\"forminator-field-radio-NaN-label-1\" for=\"forminator-field-radio-NaN-1-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I Agree\"><input type=\"radio\" name=\"radio-NaN\" value=\"one\" id=\"forminator-field-radio-NaN-1-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Agree<\/span><\/label><label id=\"forminator-field-radio-NaN-label-2\" for=\"forminator-field-radio-NaN-2-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I Disagree\"><input type=\"radio\" name=\"radio-NaN\" value=\"two\" id=\"forminator-field-radio-NaN-2-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Disagree<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-NaN\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\"><span id=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\" class=\"forminator-label\">to the use of any remaining tumor tissue, blood samples, and the DNA and RNA materials obtained from these samples for scientific research purposes, provided that the expected test results have been obtained and delivered to me, the materials are no longer required for further testing, and all personal identification information and data that could enable identification remain confidential.<\/span><label id=\"forminator-field-radio-NaN-label-1\" for=\"forminator-field-radio-NaN-1-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I Agree\"><input type=\"radio\" name=\"radio-NaN\" value=\"one\" id=\"forminator-field-radio-NaN-1-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Agree<\/span><\/label><label id=\"forminator-field-radio-NaN-label-2\" for=\"forminator-field-radio-NaN-2-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I Disagree\"><input type=\"radio\" name=\"radio-NaN\" value=\"two\" id=\"forminator-field-radio-NaN-2-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Disagree<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-NaN\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\"><span id=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\" class=\"forminator-label\">to the storage of the materials solely for use in additional studies that may be approved by me.<\/span><label id=\"forminator-field-radio-NaN-label-1\" for=\"forminator-field-radio-NaN-1-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I Agree\"><input type=\"radio\" name=\"radio-NaN\" value=\"one\" id=\"forminator-field-radio-NaN-1-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Agree<\/span><\/label><label id=\"forminator-field-radio-NaN-label-2\" for=\"forminator-field-radio-NaN-2-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I Disagree\"><input type=\"radio\" name=\"radio-NaN\" value=\"two\" id=\"forminator-field-radio-NaN-2-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Disagree<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-NaN\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\"><span id=\"forminator-radiogroup-radio-NaN-6a65939704f57-label\" class=\"forminator-label\">I understand that I will not receive any financial benefit from, nor will any compensation be paid to me for, any inventions arising from research and development conducted using my sample. I may choose not to permit such use of my sample, and this decision will not affect my test results in any way. 7. In accordance with the Turkish Personal Data Protection Law No. 6698 and applicable legislation, my personal data, including special categories of personal data such as disease-related information required for the comprehensive genomic profiling test performed by Genoks Genetics Center and the genetic data that may arise as a result of this test, whether processed alone or in combination with other data, shall be processed by Genoks Genetics Center, which collects data for the purpose of analyzing test results, in compliance with the Personal Data Protection Law. My personal data are obtained from the Test Request Form completed by my physician and from the tissue or blood samples collected, and are processed based on the consent I have provided through this form. The information obtained as a result of this test shall not be shared with anyone other than my physician without my consent and shall be stored by my physician and Genoks Genetics Center in line with the purposes specified in the Privacy Policy, in accordance with applicable law. 8. All information obtained as a result of this test may be used in scientific and clinical research and publications, provided that my consent is obtained and that my identity and all information that could enable identification remain confidential. 9. Any remaining tumor tissue from my cancer material, if I do not provide consent, shall be returned either to me or to the pathology laboratory responsible for storing the tissue; any unused tumor tissue or blood sample, or the DNA and RNA obtained from these samples, shall be retained for six months and then destroyed if I do not provide consent. If I do provide consent, such materials may be used for scientific research purposes, provided that my identity and all information that could enable identification remain confidential.<\/span><label id=\"forminator-field-radio-NaN-label-1\" for=\"forminator-field-radio-NaN-1-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I Agree\"><input type=\"radio\" name=\"radio-NaN\" value=\"one\" id=\"forminator-field-radio-NaN-1-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Agree<\/span><\/label><label id=\"forminator-field-radio-NaN-label-2\" for=\"forminator-field-radio-NaN-2-6a65939704f57\" class=\"forminator-radio forminator-radio-inline\" title=\"I Disagree\"><input type=\"radio\" name=\"radio-NaN\" value=\"two\" id=\"forminator-field-radio-NaN-2-6a65939704f57\" aria-labelledby=\"forminator-field-radio-NaN-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Disagree<\/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-2135--page-7\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2135--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=\"\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><\/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=\"196ebfd3bb\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/2138\" \/><input type=\"hidden\" name=\"form_id\" value=\"2135\"><input type=\"hidden\" name=\"page_id\" value=\"2138\"><input type=\"hidden\" name=\"form_type\" value=\"\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/genoks.com.tr\/en\/genetic-test-request-consent\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>\n  <\/div>\n\n  <div id=\"f-2136\" class=\"gx-form\">\n    <div class=\"forminator-ui forminator-custom-form forminator-custom-form-2136 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-2136\" data-uid=\"6a6593970cea7\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-2136\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-2136 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=\"2136\"\n\t\t\t\t data-color-option=\"default\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6a6593970cea7\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-2136--page-0\"\n\t\t\t\tclass=\"forminator-pagination forminator-pagination-start\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2136--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=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6a6593970cea7\" id=\"forminator-field-name-1_6a6593970cea7-label\" class=\"forminator-label\">Patient\u2019s Name<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_6a6593970cea7\" 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-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6a6593970cea7\" id=\"forminator-field-phone-1_6a6593970cea7-label\" class=\"forminator-label\">Patient Number<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6a6593970cea7\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_6a6593970cea7\" id=\"forminator-field-phone-2_6a6593970cea7-label\" class=\"forminator-label\">Contact Number<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_6a6593970cea7\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a6593970cea7\" id=\"forminator-field-email-1_6a6593970cea7-label\" class=\"forminator-label\">E-Mail<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a6593970cea7\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/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_6a6593970cea7\" id=\"forminator-field-address-1-street_address_6a6593970cea7-label\" class=\"forminator-label\">Sokak Adresi<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_6a6593970cea7\" 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_6a6593970cea7\" id=\"forminator-field-address-1-address_line_6a6593970cea7-label\" class=\"forminator-label\">Apartman, daire, vb<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_6a6593970cea7\" 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_6a6593970cea7\" id=\"forminator-field-address-1-city_6a6593970cea7-label\" class=\"forminator-label\">\u015eehir<\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"\" id=\"forminator-field-address-1-city_6a6593970cea7\" 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_6a6593970cea7\" id=\"forminator-field-address-1-state_6a6593970cea7-label\" class=\"forminator-label\">Eyalet\/\u0130l<\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"\" id=\"forminator-field-address-1-state_6a6593970cea7\" 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_6a6593970cea7\" id=\"forminator-field-address-1-zip_6a6593970cea7-label\" class=\"forminator-label\">Zip \/ Posta Kodu<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"\" id=\"forminator-field-address-1-zip_6a6593970cea7\" 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-2136__field--address-1-country_6a6593970cea7\" id=\"forminator-field-2136__field--address-1-country_6a6593970cea7-label\" class=\"forminator-label\">\u00dclke<\/label><select name=\"address-1-country\" id=\"forminator-field-2136__field--address-1-country_6a6593970cea7\" 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=\"phone-3\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-3_6a6593970cea7\" id=\"forminator-field-phone-3_6a6593970cea7-label\" class=\"forminator-label\">Patient Weight (kg)<\/label><input type=\"text\" name=\"phone-3\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-3_6a6593970cea7\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"phone-4\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-4_6a6593970cea7\" id=\"forminator-field-phone-4_6a6593970cea7-label\" class=\"forminator-label\">Patient Height (cm)<\/label><input type=\"text\" name=\"phone-4\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-4_6a6593970cea7\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_6a6593970cea7\" id=\"forminator-field-name-2_6a6593970cea7-label\" class=\"forminator-label\">Doctor\u2019s Name<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_6a6593970cea7\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"phone-5\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-5_6a6593970cea7\" id=\"forminator-field-phone-5_6a6593970cea7-label\" class=\"forminator-label\">Doctor\u2019s Phone<\/label><input type=\"text\" name=\"phone-5\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-5_6a6593970cea7\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/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-2136--page-1\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2136--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=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-6a6593970cea7-label\"><span id=\"forminator-radiogroup-radio-1-6a6593970cea7-label\" class=\"forminator-label\">I would like to take this test for Huntington\u2019s disease diagnosis. I have been informed that the gene responsible for Huntington\u2019s disease is located on the 4th chromosome. It was explained that this disease is a triplet repeat (CAG) expansion mutation. I understand that if there is an increase in the number of these triplet repeat sequences, there is a risk of developing Huntington\u2019s disease depending on the number of repeats. This blood test will determine the number of CAG repeats in my Huntington\u2019s gene. I. I understood that I would encounter 4 possible outcomes as a result of this test; 1. NEGATIVE: The CAG repeat count is within normal limits (26 repeats or fewer). This person is not at risk for Huntington\u2019s disease and will not pass the disease on to their child. 2. NORMAL\/MUTATION: The CAG repeat number is within the normal\/mutation range (27-35). The individual does not exhibit the disease, but their children are at risk. 3. INTERMEDIATE: CAG repeat count is in the intermediate range (36-39 repeats). Although it is not known for certain whether the disease will manifest at some point in this person\u2019s life, there is a risk. 4. POSITIVE: The CAG repeat count is within the Huntington\u2019s disease range (40 repeats or more). This person will develop the disease at some point in their life. A neurological evaluation is required for the initial symptoms of the disease. II. One of the most significant challenges of this test is psychological. Results in the intermediate range are difficult to interpret and cause difficulties in determining the risk status. II. Individuals with a family history of Huntington\u2019s disease but who do not yet exhibit any symptoms are considered \u201casymptomatic\u201d individuals. Considering the psychological risks, the standard testing procedure for Huntington\u2019s disease involves testing symptomatic individuals or asymptomatic adults who have received adequate counseling. IV. All information related to the test will be stored securely. Test results will be sent only to the relevant physician from the laboratory and will be disclosed only to me. I have been informed about the possibilities related to the test program and I consent to the presymptomatic test. I have been informed about the risks and benefits of the test, the difficulties encountered when evaluating the results, and the possible psychological effects of the results.<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-6a6593970cea7\" class=\"forminator-radio\" title=\"I Agree\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-6a6593970cea7\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Agree<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-6a6593970cea7\" class=\"forminator-radio\" title=\"I Disagree\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-6a6593970cea7\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Disagree<\/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-2136--page-2\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2136--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=\"\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_6a6593970cea7\" id=\"forminator-field-name-3_6a6593970cea7-label\" class=\"forminator-label\">Ad<\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"\" id=\"forminator-field-name-3_6a6593970cea7\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6a6593970cea7\" id=\"forminator-field-date-1-picker_6a6593970cea7-label\" class=\"forminator-label\">Tarih<\/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=\"Tarih Se\u00e7\" id=\"forminator-field-date-1-picker_6a6593970cea7\" 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=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Section to be completed by the relevant doctor: I have informed the patient about the Huntington\u2019s disease test and the limitations of the test.<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-4_6a6593970cea7\" id=\"forminator-field-name-4_6a6593970cea7-label\" class=\"forminator-label\">Doctor\u2019s Name<\/label><input type=\"text\" name=\"name-4\" value=\"\" placeholder=\"\" id=\"forminator-field-name-4_6a6593970cea7\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"phone-6\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-6_6a6593970cea7\" id=\"forminator-field-phone-6_6a6593970cea7-label\" class=\"forminator-label\">Doctor\u2019s Phone<\/label><input type=\"text\" name=\"phone-6\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-6_6a6593970cea7\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/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=\"707ae09696\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/2138\" \/><input type=\"hidden\" name=\"form_id\" value=\"2136\"><input type=\"hidden\" name=\"page_id\" value=\"2138\"><input type=\"hidden\" name=\"form_type\" value=\"\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/genoks.com.tr\/en\/genetic-test-request-consent\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>\n  <\/div>\n\n  <div id=\"f-2137\" class=\"gx-form\">\n    <div class=\"forminator-ui forminator-custom-form forminator-custom-form-2137 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-2137\" data-uid=\"6a659397115c2\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-2137\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-2137 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=\"2137\"\n\t\t\t\t data-color-option=\"default\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6a659397115c2\"\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-2137--page-0\"\n\t\t\t\tclass=\"forminator-pagination forminator-pagination-start\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2137--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=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Prenatal Diagnosis Test \u2013 Patient Information<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6a659397115c2\" id=\"forminator-field-name-1_6a659397115c2-label\" class=\"forminator-label\">Name and Surname<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_6a659397115c2\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6a659397115c2\" id=\"forminator-field-text-1_6a659397115c2-label\" class=\"forminator-label\">ID No.<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6a659397115c2\" id=\"forminator-field-date-1-picker_6a659397115c2-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_6a659397115c2\" 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=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-2137__field--select-1_6a659397115c2\" id=\"forminator-form-2137__field--select-1_6a659397115c2-label\" class=\"forminator-label\">Gender<\/label><select  id=\"forminator-form-2137__field--select-1_6a659397115c2\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-1\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Select\" data-search=\"false\" data-search-placeholder=\"Select\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2137__field--select-1_6a659397115c2-label\"><option value=\"\"  >Select<\/option><option value=\"Female\"  data-calculation=\"0\">Female<\/option><option value=\"Male\"  data-calculation=\"0\">Male<\/option><option value=\"Prefer not to specify\"  data-calculation=\"0\">Prefer not to specify<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_6a659397115c2\" id=\"forminator-field-date-2-picker_6a659397115c2-label\" class=\"forminator-label\">Sampling Date\/Time<\/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-2\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-2-picker_6a659397115c2\" 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=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-2137__field--select-2_6a659397115c2\" id=\"forminator-form-2137__field--select-2_6a659397115c2-label\" class=\"forminator-label\">Sampling Location<\/label><select  id=\"forminator-form-2137__field--select-2_6a659397115c2\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-2\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Select\" data-search=\"false\" data-search-placeholder=\"Select\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2137__field--select-2_6a659397115c2-label\"><option value=\"\"  >Select<\/option><option value=\"Genoks Genetics Center\"  data-calculation=\"0\">Genoks Genetics Center<\/option><option value=\"Hospital \/ Clinic\"  data-calculation=\"0\">Hospital \/ Clinic<\/option><option value=\"Other\"  data-calculation=\"0\">Other<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a659397115c2\" id=\"forminator-field-email-1_6a659397115c2-label\" class=\"forminator-label\">E-mail<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a659397115c2\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6a659397115c2\" id=\"forminator-field-phone-1_6a659397115c2-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6a659397115c2\" 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_6a659397115c2\" id=\"forminator-field-address-1-street_address_6a659397115c2-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_6a659397115c2\" 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_6a659397115c2\" id=\"forminator-field-address-1-address_line_6a659397115c2-label\" class=\"forminator-label\">Apartment, suite, etc<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_6a659397115c2\" 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_6a659397115c2\" id=\"forminator-field-address-1-city_6a659397115c2-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"\" id=\"forminator-field-address-1-city_6a659397115c2\" 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_6a659397115c2\" id=\"forminator-field-address-1-state_6a659397115c2-label\" class=\"forminator-label\">State\/Province<\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"\" id=\"forminator-field-address-1-state_6a659397115c2\" 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_6a659397115c2\" id=\"forminator-field-address-1-zip_6a659397115c2-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"\" id=\"forminator-field-address-1-zip_6a659397115c2\" 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-2137__field--address-1-country_6a659397115c2\" id=\"forminator-field-2137__field--address-1-country_6a659397115c2-label\" class=\"forminator-label\">Country<\/label><select name=\"address-1-country\" id=\"forminator-field-2137__field--address-1-country_6a659397115c2\" 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=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Physician Information<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_6a659397115c2\" id=\"forminator-field-name-2_6a659397115c2-label\" class=\"forminator-label\">Physician\u2019s Name Surname<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_6a659397115c2\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6a659397115c2\" id=\"forminator-field-text-2_6a659397115c2-label\" class=\"forminator-label\">Physician\u2019s E-mail\/Tel<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/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-2137--page-1\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2137--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=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">To be Completed by Genoks<\/h2><\/div><\/div><\/div><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_6a659397115c2\" id=\"forminator-field-date-3-picker_6a659397115c2-label\" class=\"forminator-label\">Lab. Arrival Date\/Time<\/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_6a659397115c2\" 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=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_6a659397115c2\" id=\"forminator-field-text-3_6a659397115c2-label\" class=\"forminator-label\">Receiving Person<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_6a659397115c2\" id=\"forminator-field-text-4_6a659397115c2-label\" class=\"forminator-label\">Patient Protocol No<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_6a659397115c2\" id=\"forminator-field-text-5_6a659397115c2-label\" class=\"forminator-label\">Mother Protocol No<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_6a659397115c2\" id=\"forminator-field-text-6_6a659397115c2-label\" class=\"forminator-label\">Father Protocol No<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_6a659397115c2\" id=\"forminator-field-text-7_6a659397115c2-label\" class=\"forminator-label\">Study Code<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><\/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-2137--page-2\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2137--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=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Anamnesis &amp; Physical Examination<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_6a659397115c2\" id=\"forminator-field-text-8_6a659397115c2-label\" class=\"forminator-label\">Height (cm)<\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"\" id=\"forminator-field-text-8_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-9\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-9_6a659397115c2\" id=\"forminator-field-text-9_6a659397115c2-label\" class=\"forminator-label\">Height (percentile)<\/label><input type=\"text\" name=\"text-9\" value=\"\" placeholder=\"\" id=\"forminator-field-text-9_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-10\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-10_6a659397115c2\" id=\"forminator-field-text-10_6a659397115c2-label\" class=\"forminator-label\">BW (kg)<\/label><input type=\"text\" name=\"text-10\" value=\"\" placeholder=\"\" id=\"forminator-field-text-10_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-11\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-11_6a659397115c2\" id=\"forminator-field-text-11_6a659397115c2-label\" class=\"forminator-label\">BW (percentile)<\/label><input type=\"text\" name=\"text-11\" value=\"\" placeholder=\"\" id=\"forminator-field-text-11_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-12\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-12_6a659397115c2\" id=\"forminator-field-text-12_6a659397115c2-label\" class=\"forminator-label\">HC (cm)<\/label><input type=\"text\" name=\"text-12\" value=\"\" placeholder=\"\" id=\"forminator-field-text-12_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-13\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-13_6a659397115c2\" id=\"forminator-field-text-13_6a659397115c2-label\" class=\"forminator-label\">HC (percentile)<\/label><input type=\"text\" name=\"text-13\" value=\"\" placeholder=\"\" id=\"forminator-field-text-13_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-14\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-14_6a659397115c2\" id=\"forminator-field-text-14_6a659397115c2-label\" class=\"forminator-label\">Overarm (cm)<\/label><input type=\"text\" name=\"text-14\" value=\"\" placeholder=\"\" id=\"forminator-field-text-14_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-15\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-15_6a659397115c2\" id=\"forminator-field-text-15_6a659397115c2-label\" class=\"forminator-label\">Upper \/ Lower<\/label><input type=\"text\" name=\"text-15\" value=\"\" placeholder=\"e.g. 12 \/ 10\" id=\"forminator-field-text-15_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/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_6a659397115c2\" id=\"forminator-field-textarea-1_6a659397115c2-label\" class=\"forminator-label\">Complication<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_6a659397115c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><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_6a659397115c2\" id=\"forminator-field-textarea-2_6a659397115c2-label\" class=\"forminator-label\">MRI<\/label><textarea name=\"textarea-2\" placeholder=\"\" id=\"forminator-field-textarea-2_6a659397115c2\" 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_6a659397115c2\" id=\"forminator-field-textarea-3_6a659397115c2-label\" class=\"forminator-label\">Eye Examination<\/label><textarea name=\"textarea-3\" placeholder=\"\" id=\"forminator-field-textarea-3_6a659397115c2\" 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_6a659397115c2\" id=\"forminator-field-textarea-4_6a659397115c2-label\" class=\"forminator-label\">Echocardiography<\/label><textarea name=\"textarea-4\" placeholder=\"\" id=\"forminator-field-textarea-4_6a659397115c2\" 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_6a659397115c2\" id=\"forminator-field-textarea-5_6a659397115c2-label\" class=\"forminator-label\">Metabolic Screening<\/label><textarea name=\"textarea-5\" placeholder=\"\" id=\"forminator-field-textarea-5_6a659397115c2\" 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_6a659397115c2\" id=\"forminator-field-textarea-6_6a659397115c2-label\" class=\"forminator-label\">Hearing Test<\/label><textarea name=\"textarea-6\" placeholder=\"\" id=\"forminator-field-textarea-6_6a659397115c2\" 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_6a659397115c2\" id=\"forminator-field-textarea-7_6a659397115c2-label\" class=\"forminator-label\">USG<\/label><textarea name=\"textarea-7\" placeholder=\"\" id=\"forminator-field-textarea-7_6a659397115c2\" 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_6a659397115c2\" id=\"forminator-field-textarea-8_6a659397115c2-label\" class=\"forminator-label\">Genetic Testing<\/label><textarea name=\"textarea-8\" placeholder=\"\" id=\"forminator-field-textarea-8_6a659397115c2\" 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_6a659397115c2\" id=\"forminator-field-textarea-9_6a659397115c2-label\" class=\"forminator-label\">Other Tests<\/label><textarea name=\"textarea-9\" placeholder=\"\" id=\"forminator-field-textarea-9_6a659397115c2\" 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_6a659397115c2\" id=\"forminator-field-textarea-10_6a659397115c2-label\" class=\"forminator-label\">Dysmorphic<\/label><textarea name=\"textarea-10\" placeholder=\"\" id=\"forminator-field-textarea-10_6a659397115c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/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_6a659397115c2\" id=\"forminator-field-textarea-11_6a659397115c2-label\" class=\"forminator-label\">Neurological<\/label><textarea name=\"textarea-11\" placeholder=\"\" id=\"forminator-field-textarea-11_6a659397115c2\" 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_6a659397115c2\" id=\"forminator-field-textarea-12_6a659397115c2-label\" class=\"forminator-label\">Extremities<\/label><textarea name=\"textarea-12\" placeholder=\"\" id=\"forminator-field-textarea-12_6a659397115c2\" 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_6a659397115c2\" id=\"forminator-field-textarea-13_6a659397115c2-label\" class=\"forminator-label\">Genital<\/label><textarea name=\"textarea-13\" placeholder=\"\" id=\"forminator-field-textarea-13_6a659397115c2\" 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_6a659397115c2\" id=\"forminator-field-textarea-14_6a659397115c2-label\" class=\"forminator-label\">Additional Findings<\/label><textarea name=\"textarea-14\" placeholder=\"\" id=\"forminator-field-textarea-14_6a659397115c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/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-2137--page-3\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2137--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=\"section-5\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Family History &amp; Sample Details<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-16\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-16_6a659397115c2\" id=\"forminator-field-text-16_6a659397115c2-label\" class=\"forminator-label\">Number of MR Individuals in the Family<\/label><input type=\"text\" name=\"text-16\" value=\"\" placeholder=\"\" id=\"forminator-field-text-16_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-17\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-17_6a659397115c2\" id=\"forminator-field-text-17_6a659397115c2-label\" class=\"forminator-label\">Known Hereditary Disease in the Family<\/label><input type=\"text\" name=\"text-17\" value=\"\" placeholder=\"\" id=\"forminator-field-text-17_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-18\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-18_6a659397115c2\" id=\"forminator-field-text-18_6a659397115c2-label\" class=\"forminator-label\">Mother\u2019s Name Surname<\/label><input type=\"text\" name=\"text-18\" value=\"\" placeholder=\"\" id=\"forminator-field-text-18_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-19\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-19_6a659397115c2\" id=\"forminator-field-text-19_6a659397115c2-label\" class=\"forminator-label\">Mother\u2019s ID No.<\/label><input type=\"text\" name=\"text-19\" value=\"\" placeholder=\"\" id=\"forminator-field-text-19_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-4\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-picker_6a659397115c2\" id=\"forminator-field-date-4-picker_6a659397115c2-label\" class=\"forminator-label\">Mother\u2019s 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_6a659397115c2\" 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=\"text-20\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-20_6a659397115c2\" id=\"forminator-field-text-20_6a659397115c2-label\" class=\"forminator-label\">Father\u2019s Name Surname<\/label><input type=\"text\" name=\"text-20\" value=\"\" placeholder=\"\" id=\"forminator-field-text-20_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-21\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-21_6a659397115c2\" id=\"forminator-field-text-21_6a659397115c2-label\" class=\"forminator-label\">Father\u2019s ID No.<\/label><input type=\"text\" name=\"text-21\" value=\"\" placeholder=\"\" id=\"forminator-field-text-21_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-5\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-5-picker_6a659397115c2\" id=\"forminator-field-date-5-picker_6a659397115c2-label\" class=\"forminator-label\">Father\u2019s 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_6a659397115c2\" 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-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-6a659397115c2-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-6a659397115c2-label\" class=\"forminator-label\">Control<\/span><label id=\"forminator-field-checkbox-1-1-6a659397115c2-label\" for=\"forminator-field-checkbox-1-1-6a659397115c2\" class=\"forminator-checkbox\" title=\"Photograph\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Photograph\" id=\"forminator-field-checkbox-1-1-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-1-1-6a659397115c2-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-1-2-6a659397115c2-label\" for=\"forminator-field-checkbox-1-2-6a659397115c2\" class=\"forminator-checkbox\" title=\"Consent Form\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Consent-Form\" id=\"forminator-field-checkbox-1-2-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-1-2-6a659397115c2-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-2\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-2-6a659397115c2-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-6a659397115c2-label\" class=\"forminator-label\">Material Type<\/span><label id=\"forminator-field-checkbox-2-1-6a659397115c2-label\" for=\"forminator-field-checkbox-2-1-6a659397115c2\" class=\"forminator-checkbox\" title=\"Peripheral Blood\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Peripheral-Blood\" id=\"forminator-field-checkbox-2-1-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-2-1-6a659397115c2-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-2-2-6a659397115c2-label\" for=\"forminator-field-checkbox-2-2-6a659397115c2\" class=\"forminator-checkbox\" title=\"Amniotic Fluid\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Amniotic-Fluid\" id=\"forminator-field-checkbox-2-2-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-2-2-6a659397115c2-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-2-3-6a659397115c2-label\" for=\"forminator-field-checkbox-2-3-6a659397115c2\" class=\"forminator-checkbox\" title=\"CVS\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"CVS\" id=\"forminator-field-checkbox-2-3-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-2-3-6a659397115c2-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-2-4-6a659397115c2-label\" for=\"forminator-field-checkbox-2-4-6a659397115c2\" class=\"forminator-checkbox\" title=\"Cord Blood\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Cord-Blood\" id=\"forminator-field-checkbox-2-4-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-2-4-6a659397115c2-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-2-5-6a659397115c2-label\" for=\"forminator-field-checkbox-2-5-6a659397115c2\" class=\"forminator-checkbox\" title=\"Saliva\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Saliva\" id=\"forminator-field-checkbox-2-5-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-2-5-6a659397115c2-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-2-6-6a659397115c2-label\" for=\"forminator-field-checkbox-2-6-6a659397115c2\" class=\"forminator-checkbox\" title=\"Skin Biopsy\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Skin-Biopsy\" id=\"forminator-field-checkbox-2-6-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-2-6-6a659397115c2-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-2-7-6a659397115c2-label\" for=\"forminator-field-checkbox-2-7-6a659397115c2\" class=\"forminator-checkbox\" title=\"FTA Card\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"FTA-Card\" id=\"forminator-field-checkbox-2-7-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-2-7-6a659397115c2-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-15\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-15_6a659397115c2\" id=\"forminator-field-textarea-15_6a659397115c2-label\" class=\"forminator-label\">Findings<\/label><textarea name=\"textarea-15\" placeholder=\"\" id=\"forminator-field-textarea-15_6a659397115c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-16\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-16_6a659397115c2\" id=\"forminator-field-textarea-16_6a659397115c2-label\" class=\"forminator-label\">Requested Test \/ Plan<\/label><textarea name=\"textarea-16\" placeholder=\"\" id=\"forminator-field-textarea-16_6a659397115c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/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-2137--page-4\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2137--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-6\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-6\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Family Tree<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-22\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-22_6a659397115c2\" id=\"forminator-field-text-22_6a659397115c2-label\" class=\"forminator-label\">Mother\u2019s Origin<\/label><input type=\"text\" name=\"text-22\" value=\"\" placeholder=\"\" id=\"forminator-field-text-22_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-23\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-23_6a659397115c2\" id=\"forminator-field-text-23_6a659397115c2-label\" class=\"forminator-label\">Father\u2019s Origin<\/label><input type=\"text\" name=\"text-23\" value=\"\" placeholder=\"\" id=\"forminator-field-text-23_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/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-3-6a659397115c2-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-3-6a659397115c2-label\" class=\"forminator-label\">Additional<\/span><label id=\"forminator-field-checkbox-3-1-6a659397115c2-label\" for=\"forminator-field-checkbox-3-1-6a659397115c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Kinship\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Kinship\" id=\"forminator-field-checkbox-3-1-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-3-1-6a659397115c2-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Kinship<\/span><\/label><label id=\"forminator-field-checkbox-3-2-6a659397115c2-label\" for=\"forminator-field-checkbox-3-2-6a659397115c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Same Village\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Same-Village\" id=\"forminator-field-checkbox-3-2-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-3-2-6a659397115c2-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Same Village<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-24\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-24_6a659397115c2\" id=\"forminator-field-text-24_6a659397115c2-label\" class=\"forminator-label\">G1<\/label><input type=\"text\" name=\"text-24\" value=\"\" placeholder=\"\" id=\"forminator-field-text-24_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-25\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-25_6a659397115c2\" id=\"forminator-field-text-25_6a659397115c2-label\" class=\"forminator-label\">G2<\/label><input type=\"text\" name=\"text-25\" value=\"\" placeholder=\"\" id=\"forminator-field-text-25_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-26\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-26_6a659397115c2\" id=\"forminator-field-text-26_6a659397115c2-label\" class=\"forminator-label\">G3<\/label><input type=\"text\" name=\"text-26\" value=\"\" placeholder=\"\" id=\"forminator-field-text-26_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-27\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-27_6a659397115c2\" id=\"forminator-field-text-27_6a659397115c2-label\" class=\"forminator-label\">G4<\/label><input type=\"text\" name=\"text-27\" value=\"\" placeholder=\"\" id=\"forminator-field-text-27_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-28\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-28_6a659397115c2\" id=\"forminator-field-text-28_6a659397115c2-label\" class=\"forminator-label\">G5<\/label><input type=\"text\" name=\"text-28\" value=\"\" placeholder=\"\" id=\"forminator-field-text-28_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-29\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-29_6a659397115c2\" id=\"forminator-field-text-29_6a659397115c2-label\" class=\"forminator-label\">G6<\/label><input type=\"text\" name=\"text-29\" value=\"\" placeholder=\"\" id=\"forminator-field-text-29_6a659397115c2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/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-2137--page-5\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2137--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=\"section-7\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Family Tree<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_6a659397115c2\" id=\"forminator-field-name-3_6a659397115c2-label\" class=\"forminator-label\">Mother\u2019s Origin<\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"\" id=\"forminator-field-name-3_6a659397115c2\" 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-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-4_6a659397115c2\" id=\"forminator-field-name-4_6a659397115c2-label\" class=\"forminator-label\">Father\u2019s Origin<\/label><input type=\"text\" name=\"name-4\" value=\"\" placeholder=\"\" id=\"forminator-field-name-4_6a659397115c2\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"checkbox-4\" class=\"forminator-field-checkbox forminator-col forminator-col-4 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-4-6a659397115c2-label\"><label id=\"forminator-field-checkbox-4-1-6a659397115c2-label\" for=\"forminator-field-checkbox-4-1-6a659397115c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Kinship\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"one\" id=\"forminator-field-checkbox-4-1-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-4-1-6a659397115c2-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Kinship<\/span><\/label><label id=\"forminator-field-checkbox-4-2-6a659397115c2-label\" for=\"forminator-field-checkbox-4-2-6a659397115c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Same Village\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"two\" id=\"forminator-field-checkbox-4-2-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-4-2-6a659397115c2-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Same Village<\/span><\/label><\/div><\/div><\/div><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-5-6a659397115c2-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-5-6a659397115c2-label\" class=\"forminator-label\">Control<\/span><label id=\"forminator-field-checkbox-5-1-6a659397115c2-label\" for=\"forminator-field-checkbox-5-1-6a659397115c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Photograph\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"one\" id=\"forminator-field-checkbox-5-1-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-5-1-6a659397115c2-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-5-2-6a659397115c2-label\" for=\"forminator-field-checkbox-5-2-6a659397115c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Consent Form\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"two\" id=\"forminator-field-checkbox-5-2-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-5-2-6a659397115c2-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-6\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-6-6a659397115c2-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-6-6a659397115c2-label\" class=\"forminator-label\">Material Type<\/span><label id=\"forminator-field-checkbox-6-1-6a659397115c2-label\" for=\"forminator-field-checkbox-6-1-6a659397115c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Peripheral Blood\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"one\" id=\"forminator-field-checkbox-6-1-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-6-1-6a659397115c2-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-6-2-6a659397115c2-label\" for=\"forminator-field-checkbox-6-2-6a659397115c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Amniotic Fluid\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"two\" id=\"forminator-field-checkbox-6-2-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-6-2-6a659397115c2-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-6-3-6a659397115c2-label\" for=\"forminator-field-checkbox-6-3-6a659397115c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"CVS\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"CVS\" id=\"forminator-field-checkbox-6-3-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-6-3-6a659397115c2-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-6-4-6a659397115c2-label\" for=\"forminator-field-checkbox-6-4-6a659397115c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Cord Blood\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Cord-Blood\" id=\"forminator-field-checkbox-6-4-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-6-4-6a659397115c2-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-6-5-6a659397115c2-label\" for=\"forminator-field-checkbox-6-5-6a659397115c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Saliva\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Saliva\" id=\"forminator-field-checkbox-6-5-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-6-5-6a659397115c2-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-6-6-6a659397115c2-label\" for=\"forminator-field-checkbox-6-6-6a659397115c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Skin Biopsy\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Skin-Biopsy\" id=\"forminator-field-checkbox-6-6-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-6-6-6a659397115c2-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-6-7-6a659397115c2-label\" for=\"forminator-field-checkbox-6-7-6a659397115c2\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"FTA Card\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"FTA-Card\" id=\"forminator-field-checkbox-6-7-6a659397115c2\" aria-labelledby=\"forminator-field-checkbox-6-7-6a659397115c2-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-17\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-17_6a659397115c2\" id=\"forminator-field-textarea-17_6a659397115c2-label\" class=\"forminator-label\">Findings<\/label><textarea name=\"textarea-17\" placeholder=\"\" id=\"forminator-field-textarea-17_6a659397115c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><div id=\"textarea-18\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-18_6a659397115c2\" id=\"forminator-field-textarea-18_6a659397115c2-label\" class=\"forminator-label\">Requested Test \/ Plan<\/label><textarea name=\"textarea-18\" placeholder=\"\" id=\"forminator-field-textarea-18_6a659397115c2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/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-2137--page-6\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2137--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-8\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-6a659397115c2-label\"><span id=\"forminator-radiogroup-radio-1-6a659397115c2-label\" class=\"forminator-label\">Your physician will decide on the sample to be taken for the test and the method of collection. Special samples such as amniotic fluid, chorionic villus biopsy (CVS), cord blood, abortion material and biopsy will be taken by your physician under special conditions by informing you with a separate consent form. Since karyotype analysis, which is one of the genetic tests, is performed from living cells, the sample to be studied must reach the laboratory under the right conditions, and if sufficient sample cannot be taken for analysis in the first attempt or if cell growth is not achieved in cell culture, the attempt may need to be repeated or it may not be possible to take a sample again. Genoks Genetics Center is not responsible for such situations. The remaining fee will be refunded after deducting the cost of the kit spent on non-growing samples. In rare cases, genetic tests may be difficult to interpret and may not reflect the actual result in cases such as maternal contamination (maternal contamination), both normal and abnormal cells in the baby (mosaicism), chromosomal abnormalities that may occur during the cell culture in the laboratory (pseudo-mosaicism). If any pathology is found in the report, a second biopsy may be required to confirm the result. Genetic testing is aimed at the risk being investigated and is not intended to provide information about other diseases, but in some cases, other genetic or non-genetic conditions may be detected in the baby with the risk result. Genetic testing does not necessarily indicate all diseases. Even if the test result is normal, conditions that may occur for reasons other than the genetic disease analyzed, such as a different genetic disease, physical anomaly or cognitive impairment, may be observed. Additional cytogenetic or molecular tests may be needed to complete the genetic test, and in some cases it may be necessary to take samples from the parents or other family members for genetic testing. According to the provision in subparagraph (e) of paragraph 1 of Article 18 of Section 6 of the Regulation on Genetic Diseases Evaluation Centers, gender cannot be specified in cases other than gonosomal aneuploidy. Provided that my identity information remains confidential, I consent to the use of all my genetic data in scientific congresses, meetings and journals in written and\/or verbal form.<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-6a659397115c2\" class=\"forminator-radio forminator-radio-inline\" title=\"I Agree\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-6a659397115c2\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Agree<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-6a659397115c2\" class=\"forminator-radio forminator-radio-inline\" title=\"I Disagree\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-6a659397115c2\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Disagree<\/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-2137--page-7\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2137--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-5\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-6a659397115c2-label\"><span id=\"forminator-radiogroup-radio-2-6a659397115c2-label\" class=\"forminator-label\">Confidentiality\/Management of Information Our laboratory is responsible for managing all information obtained or generated during the course of its operations, in compliance with legal obligations. Our laboratory ensures the confidentiality of users through legally binding methods, such as a contract with the user. However, in cases where the requirements of the law, legislation, etc. differ from the requirements of the standard, legal provisions apply. If a legal authority requests access to user\/patient information without their knowledge, the user\/patient will not be informed that their information has been shared. This situation is defined below. Genoks Laboratory is responsible for the management of all patient information obtained or created during the performance of laboratory activities in accordance with legally enforceable agreements. The management of patient information includes confidentiality and privacy. Our laboratory informs the customer and\/or patient in advance about the information it wishes to make public. Except for the information made public by the customer and\/or patient, or when agreed between the laboratory and the patient (for example, to respond to complaints), all other information is considered private information and is considered confidential. Confidentiality\/Disclosure of Information When required by law or authorized by contractual arrangements to release confidential information, Genoks Laboratory informs the patient of the information released, unless prohibited by law. Information about the patient from a source other than the patient (e.g. complainant, regulator) is kept confidential by the laboratory. The identity of the source is kept confidential by the laboratory and is not shared with the patient unless agreed with the source. Confidentiality\/Dissemination of Information Ethical Behavior Our laboratory does not engage in practices restricted by law and avoids situations that cause conflict of interest. The maintenance of ethical standards is a shared responsibility among all laboratory and healthcare personnel, including sample collection staff, as defined in the statement of impartiality and confidentiality signed by senior management. All patient samples are treated equally. There is no discrimination based on gender, age or race in the analysis of patient samples. All samples are analyzed for the right patient at the right time and with the right result.<\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-6a659397115c2\" class=\"forminator-radio forminator-radio-inline\" title=\"I Agree\"><input type=\"radio\" name=\"radio-2\" value=\"one\" id=\"forminator-field-radio-2-1-6a659397115c2\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Agree<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-6a659397115c2\" class=\"forminator-radio forminator-radio-inline\" title=\"I Disagree\"><input type=\"radio\" name=\"radio-2\" value=\"two\" id=\"forminator-field-radio-2-2-6a659397115c2\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I Disagree<\/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-2137--page-8\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-2137--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=\"\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><\/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=\"24be159fd2\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/2138\" \/><input type=\"hidden\" name=\"form_id\" value=\"2137\"><input type=\"hidden\" name=\"page_id\" value=\"2138\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/genoks.com.tr\/en\/genetic-test-request-consent\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>\n  <\/div>\n<\/div>\n\n<style>\n  .gx-form { display:none; }\n  .gx-form.is-active { display:block; }\n  .gx-form-switcher { margin: 0 0 16px; }\n  #gxFormSelect { width: 100%; max-width: 680px; padding: 10px 12px; }\n<\/style>\n\n<script>\n(function(){\n  const select = document.getElementById('gxFormSelect');\n  const forms  = document.querySelectorAll('.gx-form');\n\n  function showForm(id){\n    forms.forEach(el => el.classList.remove('is-active'));\n    if(!id) return;\n    const target = document.getElementById(id);\n    if(target) target.classList.add('is-active');\n  }\n\n  \/\/ \u0130lk a\u00e7\u0131l\u0131\u015fta bo\u015f\n  showForm('');\n\n  select.addEventListener('change', function(){\n    showForm(this.value);\n  });\n})();\n<\/script>\n\n\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Please select the relevant genetic test or consent form from the list below. Once a selection is made, the corresponding form will be displayed automatically. Kindly ensure that all information is completed accurately and that the consent sections are reviewed<span class=\"excerpt-hellip\"> [\u2026]<\/span><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-2138","page","type-page","status-publish","hentry"],"aioseo_notices":[],"aioseo_head":"\n\t\t<!-- All in One SEO Pro 4.9.5.2 - aioseo.com -->\n\t<meta name=\"description\" content=\"Please select the relevant genetic test or consent form from the list below. Once a selection is made, the corresponding form will be displayed automatically. Kindly ensure that all information is completed accurately and that the consent sections are reviewed carefully before submission. These forms are required to proceed with genetic testing and related laboratory\" \/>\n\t<meta name=\"robots\" content=\"max-image-preview:large\" \/>\n\t<meta name=\"google-site-verification\" content=\"ljUyqtBGG8DXpxob7UI4c9oJrZg8sQi-yc4woRonnis\" \/>\n\t<link rel=\"canonical\" href=\"https:\/\/genoks.com.tr\/en\/genetic-test-request-consent\/\" \/>\n\t<meta name=\"generator\" content=\"All in One SEO Pro (AIOSEO) 4.9.5.2\" \/>\n\t\t<meta property=\"og:locale\" content=\"en_US\" \/>\n\t\t<meta property=\"og:site_name\" content=\"Genoks Genetics | NIPT, Carrier Screening, Oncogenetics and WES Services - Shedding Light on Your Genes!\" \/>\n\t\t<meta property=\"og:type\" content=\"article\" \/>\n\t\t<meta property=\"og:title\" content=\"Genetic Test Request &amp; Consent - Genoks Genetics | NIPT, Carrier Screening, Oncogenetics and WES Services\" \/>\n\t\t<meta property=\"og:description\" content=\"Please select the relevant genetic test or consent form from the list below. Once a selection is made, the corresponding form will be displayed automatically. Kindly ensure that all information is completed accurately and that the consent sections are reviewed carefully before submission. These forms are required to proceed with genetic testing and related laboratory\" \/>\n\t\t<meta property=\"og:url\" content=\"https:\/\/genoks.com.tr\/en\/genetic-test-request-consent\/\" \/>\n\t\t<meta property=\"og:image\" content=\"https:\/\/genoks.com.tr\/wp-content\/uploads\/2025\/06\/genoks.svg\" \/>\n\t\t<meta property=\"og:image:secure_url\" content=\"https:\/\/genoks.com.tr\/wp-content\/uploads\/2025\/06\/genoks.svg\" \/>\n\t\t<meta property=\"article:published_time\" content=\"2026-01-04T16:53:55+00:00\" \/>\n\t\t<meta property=\"article:modified_time\" content=\"2026-01-04T16:57:17+00:00\" \/>\n\t\t<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/GenoksGHTM\" \/>\n\t\t<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n\t\t<meta name=\"twitter:site\" content=\"@Genoks_GHTM\" \/>\n\t\t<meta name=\"twitter:title\" content=\"Genetic Test Request &amp; Consent - Genoks Genetics | NIPT, Carrier Screening, Oncogenetics and WES Services\" \/>\n\t\t<meta name=\"twitter:description\" content=\"Please select the relevant genetic test or consent form from the list below. Once a selection is made, the corresponding form will be displayed automatically. Kindly ensure that all information is completed accurately and that the consent sections are reviewed carefully before submission. 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