{"id":427,"date":"2018-05-28T15:36:38","date_gmt":"2018-05-28T15:36:38","guid":{"rendered":"https:\/\/www.chrisgreeff.com\/?page_id=427"},"modified":"2019-12-05T15:28:22","modified_gmt":"2019-12-05T15:28:22","slug":"forms","status":"publish","type":"page","link":"https:\/\/www.chrisgreeff.com\/index.php\/forms\/","title":{"rendered":"Forms"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; fullwidth=&#8221;on&#8221; next_background_color=&#8221;#32bcf2&#8243; admin_label=&#8221;Hero&#8221; _builder_version=&#8221;3.22&#8243; background_color=&#8221;#ffffff&#8221; background_color_gradient_direction=&#8221;165deg&#8221; background_image=&#8221;https:\/\/www.chrisgreeff.com\/wp-content\/uploads\/2018\/07\/iStock-519868593.jpg&#8221; background_position=&#8221;top_center&#8221; bottom_divider_style=&#8221;wave2&#8243; bottom_divider_height=&#8221;150px&#8221; bottom_divider_flip=&#8221;horizontal&#8221; custom_css_main_element=&#8221;height:60vh;&#8221;][et_pb_fullwidth_header background_overlay_color=&#8221;rgba(255,255,255,0)&#8221; _builder_version=&#8221;3.16&#8243; title_font=&#8221;Fredoka One||||||||&#8221; title_text_color=&#8221;#262f71&#8243; title_font_size=&#8221;50px&#8221; title_line_height=&#8221;1.3em&#8221; content_font_size=&#8221;16px&#8221; content_line_height=&#8221;1.8em&#8221; background_color=&#8221;rgba(126,190,197,0)&#8221; custom_button_one=&#8221;on&#8221; button_one_text_size=&#8221;14px&#8221; button_one_text_color=&#8221;#ffffff&#8221; button_one_bg_color=&#8221;#ffb9cc&#8221; button_one_border_width=&#8221;8px&#8221; button_one_border_color=&#8221;#ffb9cc&#8221; button_one_border_radius=&#8221;100px&#8221; button_one_font=&#8221;Nunito|700||on|||||&#8221; button_one_use_icon=&#8221;off&#8221; custom_button_two=&#8221;on&#8221; button_two_text_size=&#8221;14px&#8221; button_two_text_color=&#8221;#88d4f2&#8243; button_two_border_width=&#8221;6px&#8221; button_two_border_color=&#8221;rgba(255,255,255,0)&#8221; button_two_border_radius=&#8221;86px&#8221; button_two_font=&#8221;Nunito|700||on|||||&#8221; button_two_use_icon=&#8221;off&#8221; background_layout=&#8221;light&#8221; custom_margin=&#8221;|||&#8221; custom_padding=&#8221;150px||150px|&#8221; box_shadow_style_button_one=&#8221;preset3&#8243; box_shadow_color_button_one=&#8221;rgba(255,185,204,0.6)&#8221; box_shadow_style_button_two=&#8221;preset5&#8243; box_shadow_vertical_button_two=&#8221;0px&#8221; box_shadow_spread_button_two=&#8221;2px&#8221; box_shadow_color_button_two=&#8221;rgba(136,212,242,0)&#8221; button_two_text_color_hover=&#8221;#ffffff&#8221; button_two_border_color_hover=&#8221;#88d4f2&#8243; button_two_bg_color_hover=&#8221;#88d4f2&#8243; saved_tabs=&#8221;all&#8221; button_one_text_size__hover_enabled=&#8221;off&#8221; button_two_text_size__hover_enabled=&#8221;off&#8221; button_one_text_color__hover_enabled=&#8221;off&#8221; button_two_text_color__hover_enabled=&#8221;on&#8221; button_two_text_color__hover=&#8221;#ffffff&#8221; button_one_border_width__hover_enabled=&#8221;off&#8221; button_two_border_width__hover_enabled=&#8221;off&#8221; button_one_border_color__hover_enabled=&#8221;off&#8221; button_two_border_color__hover_enabled=&#8221;on&#8221; button_two_border_color__hover=&#8221;#88d4f2&#8243; button_one_border_radius__hover_enabled=&#8221;off&#8221; button_two_border_radius__hover_enabled=&#8221;off&#8221; button_one_letter_spacing__hover_enabled=&#8221;off&#8221; button_two_letter_spacing__hover_enabled=&#8221;off&#8221; button_one_bg_color__hover_enabled=&#8221;off&#8221; button_two_bg_color__hover_enabled=&#8221;on&#8221; button_two_bg_color__hover=&#8221;#88d4f2&#8243;]&nbsp;<br \/>\n[\/et_pb_fullwidth_header][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;Features&#8221; _builder_version=&#8221;3.22&#8243; background_color=&#8221;#32bcf2&#8243; background_blend=&#8221;overlay&#8221; custom_padding=&#8221;80px||80px|&#8221; top_divider_height=&#8221;150px&#8221; top_divider_flip=&#8221;horizontal&#8221; locked=&#8221;off&#8221;][et_pb_row _builder_version=&#8221;4.0.7&#8243; hover_enabled=&#8221;0&#8243; custom_margin_last_edited=&#8221;on|phone&#8221; custom_margin_tablet=&#8221;-75px||||false|false&#8221; custom_margin_phone=&#8221;-99px||||false|false&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;3.25&#8243; custom_padding=&#8221;|||&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text _builder_version=&#8221;4.0.7&#8243; text_font=&#8221;Fredoka One||||||||&#8221; text_text_color=&#8221;#ffffff&#8221; text_font_size=&#8221;45px&#8221; header_line_height=&#8221;0em&#8221; header_2_font=&#8221;Fredoka One||||||||&#8221; header_2_text_align=&#8221;center&#8221; header_2_font_size=&#8221;46px&#8221; header_2_line_height=&#8221;1.3em&#8221; background_layout=&#8221;dark&#8221; max_width=&#8221;700px&#8221; module_alignment=&#8221;center&#8221; custom_margin=&#8221;|||&#8221; animation_style=&#8221;slide&#8221; animation_direction=&#8221;top&#8221; animation_intensity_slide=&#8221;5%&#8221; animation_starting_opacity=&#8221;100%&#8221; hover_enabled=&#8221;0&#8243; text_font_size_last_edited=&#8221;on|phone&#8221; text_font_size_tablet=&#8221;40px&#8221; text_line_height=&#8221;1.1em&#8221; text_font_size_phone=&#8221;25px&#8221; text_orientation=&#8221;center&#8221;]New Patient Application Form<br \/>\n[\/et_pb_text][et_pb_text _builder_version=&#8221;3.27.4&#8243;]\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_2' ><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/index.php\/wp-json\/wp\/v2\/pages\/427#gf_2'>\n        <div id='gf_progressbar_wrapper_2' class='gf_progressbar_wrapper'>\n            <h3 class='gf_progressbar_title'>Step 1 of 5\n        <\/h3>\n            <div class='gf_progressbar' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_20' style='width:20%;'><span>20%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform_body'><div id='gform_page_2_1' class='gform_page' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'><li id='field_2_84'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>PATIENT DETAILS<\/h2><\/li><li id='field_2_86'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_86' >Title<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_86' id='input_2_86' class='small gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='Mr' >Mr<\/option><option value='Mrs' >Mrs<\/option><option value='Miss' >Miss<\/option><option value='Dr' >Dr<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id='field_2_12'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >FULL NAMES AND SURNAMES<span class='gfield_required'>*<\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name' id='input_2_12'>\n                            \n                            <span id='input_2_12_3_container' class='name_first' >\n                                                    <input type='text' name='input_12.3' id='input_2_12_3' value='' aria-label='First name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_2_12_3' >First<\/label>\n                                                <\/span>\n                            <span id='input_2_12_4_container' class='name_middle' >\n                                                    <input type='text' name='input_12.4' id='input_2_12_4' value='' aria-label='Middle name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_2_12_4' >Middle<\/label>\n                                                <\/span>\n                            <span id='input_2_12_6_container' class='name_last' >\n                                                    <input type='text' name='input_12.6' id='input_2_12_6' value='' aria-label='Last name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_2_12_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_2_14'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_14' >Normally Called<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_2_14' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_8'  class='gfield gf_left_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Gender<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_8'><li class='gchoice_2_8_0'><input name='input_8' type='radio' value='Male'  id='choice_2_8_0'    \/><label for='choice_2_8_0' id='label_2_8_0'>Male<\/label><\/li><li class='gchoice_2_8_1'><input name='input_8' type='radio' value='Female'  id='choice_2_8_1'    \/><label for='choice_2_8_1' id='label_2_8_1'>Female<\/label><\/li><\/ul><\/div><\/li><li id='field_2_98'  class='gfield gf_middle_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_98' >ID Number<\/label><div class='ginput_container ginput_container_number'><input name='input_98' id='input_2_98' type='text'    value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_9'  class='gfield gf_right_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Language Preference<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_9'><li class='gchoice_2_9_0'><input name='input_9' type='radio' value='English'  id='choice_2_9_0'    \/><label for='choice_2_9_0' id='label_2_9_0'>English<\/label><\/li><li class='gchoice_2_9_1'><input name='input_9' type='radio' value='Afrikaans'  id='choice_2_9_1'    \/><label for='choice_2_9_1' id='label_2_9_1'>Afrikaans<\/label><\/li><\/ul><\/div><\/li><li id='field_2_16'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_16' >School Name (if applicable)<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_2_16' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_18'  class='gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_18' >Grade (if applicable)<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_2_18' type='text' value='' class='small'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_19'  class='gfield gf_left_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_19' >Referred By<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_2_19' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_21'  class='gfield gf_middle_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_21' >Your Dentist Name<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_2_21' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_99'  class='gfield gf_right_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_99' >Your Dentist telephone Number<\/label><div class='ginput_container ginput_container_number'><input name='input_99' id='input_2_99' type='text'    value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                         <input type='button' id='gform_next_button_2_92' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_2' class='gform_fields top_label form_sublabel_below description_below'><li id='field_2_33'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>MEDICAL AID DETAILS<\/h2><\/li><li id='field_2_23'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_23' >Scheme name<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_2_23' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_25'  class='gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_25' >Plan<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_2_25' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_24'  class='gfield gf_left_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_24' >Medical Aid Number<\/label><div class='ginput_container ginput_container_number'><input name='input_24' id='input_2_24' type='text'    value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_26'  class='gfield gf_middle_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Joining Date<\/label><div id='input_2_26' class='ginput_container ginput_container_date'><div class='clear-multi'><div class='gfield_date_dropdown_month ginput_container ginput_container_date' id='input_2_26_1_container'><select name='input_26[]' id='input_2_26_1'   aria-label='Month'><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date' id='input_2_26_2_container'><select name='input_26[]' id='input_2_26_2'   aria-label='Day'><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date' id='input_2_26_3_container'><select name='input_26[]' id='input_2_26_3'   aria-label='Year'><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id='field_2_28'  class='gfield gf_right_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_28' >Dependent Number (if applicable)<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_2_28' type='text' value='' class='small'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_27'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Full Name &amp; Surname of Principal Member<\/label><div class='ginput_complex ginput_container no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name' id='input_2_27'>\n                            \n                            <span id='input_2_27_3_container' class='name_first' >\n                                                    <input type='text' name='input_27.3' id='input_2_27_3' value='' aria-label='First name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_2_27_3' >First<\/label>\n                                                <\/span>\n                            <span id='input_2_27_4_container' class='name_middle' >\n                                                    <input type='text' name='input_27.4' id='input_2_27_4' value='' aria-label='Middle name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_2_27_4' >Middle<\/label>\n                                                <\/span>\n                            <span id='input_2_27_6_container' class='name_last' >\n                                                    <input type='text' name='input_27.6' id='input_2_27_6' value='' aria-label='Last name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_2_27_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><div class='gfield_description' id='gfield_description_2_27'>Kindly note that -  We do not deal with medical schemes. You are responsible to submit the account to your medical scheme. You are responsible to establish your orthodontic benefits from your medical aid. (Kindly refer to paragraph 3 of the financial policy)<\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_2_93' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"1\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"1\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_93' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_3' class='gform_fields top_label form_sublabel_below description_below'><li id='field_2_34'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>DETAILS OF PERSON RESPONSIBLE FOR ACCOUNT<\/h2><\/li><li id='field_2_87'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_87' >Title<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_87' id='input_2_87' class='small gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='Mr' >Mr<\/option><option value='Mrs' >Mrs<\/option><option value='Miss' >Miss<\/option><option value='Dr' >Dr<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id='field_2_52'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >FULL Names and Surname<span class='gfield_required'>*<\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name' id='input_2_52'>\n                            \n                            <span id='input_2_52_3_container' class='name_first' >\n                                                    <input type='text' name='input_52.3' id='input_2_52_3' value='' aria-label='First name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_2_52_3' >First<\/label>\n                                                <\/span>\n                            <span id='input_2_52_4_container' class='name_middle' >\n                                                    <input type='text' name='input_52.4' id='input_2_52_4' value='' aria-label='Middle name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_2_52_4' >Middle<\/label>\n                                                <\/span>\n                            <span id='input_2_52_6_container' class='name_last' >\n                                                    <input type='text' name='input_52.6' id='input_2_52_6' value='' aria-label='Last name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_2_52_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_2_53'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_53' >ID Number<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_2_53' type='text' value='' class='medium' maxlength='13'    aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_54'  class='gfield gf_left_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_54' >Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_54' id='input_2_54' type='text' value='' class='medium'    aria-invalid=\"false\"  \/><\/div><\/li><li id='field_2_55'  class='gfield gf_middle_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_55' >Cell Phone<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_55' id='input_2_55' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id='field_2_56'  class='gfield gf_right_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_56' >Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_56' id='input_2_56' type='text' value='' class='medium'    aria-invalid=\"false\"  \/><\/div><\/li><li id='field_2_57'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_57' >Fax<\/label><div class='ginput_container ginput_container_phone'><input name='input_57' id='input_2_57' type='text' value='' class='medium'    aria-invalid=\"false\"  \/><\/div><\/li><li id='field_2_58'  class='gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_58' >Email<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_58' id='input_2_58' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" \/>\n                        <\/div><\/li><li id='field_2_44'  class='gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Residential Address<span class='gfield_required'>*<\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_2_44' >\n                         <span class='ginput_full address_line_1' id='input_2_44_1_container' >\n                                        <input type='text' name='input_44.1' id='input_2_44_1' value=''    aria-required=\"true\"\/>\n                                        <label for='input_2_44_1' id='input_2_44_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2' id='input_2_44_2_container' >\n                                        <input type='text' name='input_44.2' id='input_2_44_2' value=''   \/>\n                                        <label for='input_2_44_2' id='input_2_44_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_2_44_3_container' >\n                                    <input type='text' name='input_44.3' id='input_2_44_3' value=''    aria-required=\"true\"\/>\n                                    <label for='input_2_44_3' id='input_2_44_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_2_44_4_container' >\n                                        <input type='text' name='input_44.4' id='input_2_44_4' value=''      aria-required=\"true\"\/>\n                                        <label for='input_2_44_4' id='input_2_44_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_2_44_5_container' >\n                                    <input type='text' name='input_44.5' id='input_2_44_5' value=''    aria-required=\"true\"\/>\n                                    <label for='input_2_44_5' id='input_2_44_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country' id='input_2_44_6_container' >\n                                        <select name='input_44.6' id='input_2_44_6'   aria-required=\"true\"><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_2_44_6' id='input_2_44_6_label' >Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_2_42'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_42' >Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_2_42' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_43'  class='gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_43' >Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_2_43' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_51'  class='gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Way in which to receive correspondence<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_51'><li class='gchoice_2_51_0'><input name='input_51' type='radio' value='E-mail'  id='choice_2_51_0'    \/><label for='choice_2_51_0' id='label_2_51_0'>E-mail<\/label><\/li><li class='gchoice_2_51_1'><input name='input_51' type='radio' value='At Practice'  id='choice_2_51_1'    \/><label for='choice_2_51_1' id='label_2_51_1'>At Practice<\/label><\/li><\/ul><\/div><\/li><li id='field_2_49'  class='gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_49' >Email<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_49' id='input_2_49' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" \/>\n                        <\/div><\/li><li id='field_2_40'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Work Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_2_40' >\n                         <span class='ginput_full address_line_1' id='input_2_40_1_container' >\n                                        <input type='text' name='input_40.1' id='input_2_40_1' value=''    \/>\n                                        <label for='input_2_40_1' id='input_2_40_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2' id='input_2_40_2_container' >\n                                        <input type='text' name='input_40.2' id='input_2_40_2' value=''   \/>\n                                        <label for='input_2_40_2' id='input_2_40_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_2_40_3_container' >\n                                    <input type='text' name='input_40.3' id='input_2_40_3' value=''    \/>\n                                    <label for='input_2_40_3' id='input_2_40_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_2_40_4_container' >\n                                        <input type='text' name='input_40.4' id='input_2_40_4' value=''      \/>\n                                        <label for='input_2_40_4' id='input_2_40_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_2_40_5_container' >\n                                    <input type='text' name='input_40.5' id='input_2_40_5' value=''    \/>\n                                    <label for='input_2_40_5' id='input_2_40_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country' id='input_2_40_6_container' >\n                                        <select name='input_40.6' id='input_2_40_6'   ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_2_40_6' id='input_2_40_6_label' >Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_2_37'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Details of Spouse \/ Partner<\/label><div class='ginput_complex ginput_container no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name' id='input_2_37'>\n                            \n                            <span id='input_2_37_3_container' class='name_first' >\n                                                    <input type='text' name='input_37.3' id='input_2_37_3' value='' aria-label='First name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_2_37_3' >First<\/label>\n                                                <\/span>\n                            <span id='input_2_37_4_container' class='name_middle' >\n                                                    <input type='text' name='input_37.4' id='input_2_37_4' value='' aria-label='Middle name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_2_37_4' >Middle<\/label>\n                                                <\/span>\n                            <span id='input_2_37_6_container' class='name_last' >\n                                                    <input type='text' name='input_37.6' id='input_2_37_6' value='' aria-label='Last name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_2_37_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_2_38'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_38' >Spouse ID Number (if applicable)<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_2_38' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_45'  class='gfield gf_left_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_45' >Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_45' id='input_2_45' type='text' value='' class='medium'    aria-invalid=\"false\"  \/><\/div><\/li><li id='field_2_47'  class='gfield gf_middle_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_47' >Cell Phone<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_47' id='input_2_47' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id='field_2_46'  class='gfield gf_right_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_46' >Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_46' id='input_2_46' type='text' value='' class='medium'    aria-invalid=\"false\"  \/><\/div><\/li><li id='field_2_48'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_48' >Fax<\/label><div class='ginput_container ginput_container_phone'><input name='input_48' id='input_2_48' type='text' value='' class='medium'    aria-invalid=\"false\"  \/><\/div><\/li><li id='field_2_50'  class='gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_50' >Email<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_50' id='input_2_50' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" \/>\n                        <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_2_94' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_94' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"4\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"4\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_4' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_4' class='gform_fields top_label form_sublabel_below description_below'><li id='field_2_59'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>PATIENTS SIGNIFICANT MEDICAL HISTORY<\/h2><\/li><li id='field_2_68'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_68' >VERY IMPORTANT: Allergies, Heart Problems, Rheumatic Fever History, Diabetes, Epilepsy, Osteoporosis, Current Medication, Etc.<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_2_68' type='text' value='' class='large'  aria-describedby=\"gfield_description_2_68\"    aria-invalid=\"false\" \/><\/div><div class='gfield_description' id='gfield_description_2_68'>(Please list all or any known allergies and\/or illnesses. If unsure of any allergies and\/or illnesses please write \"None known\"). Complete medical history form available at reception, if required.<\/div><\/li><li id='field_2_67'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Tonsils \/ Adenoids still present?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_67'><li class='gchoice_2_67_0'><input name='input_67' type='radio' value='Yes'  id='choice_2_67_0'    \/><label for='choice_2_67_0' id='label_2_67_0'>Yes<\/label><\/li><li class='gchoice_2_67_1'><input name='input_67' type='radio' value='Removed'  id='choice_2_67_1'    \/><label for='choice_2_67_1' id='label_2_67_1'>Removed<\/label><\/li><\/ul><\/div><\/li><li id='field_2_62'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_62' >Reason for Seeking Treatment<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_62' id='input_2_62' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_2_63'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Have you had previous orthodontic treatment?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_63'><li class='gchoice_2_63_0'><input name='input_63' type='radio' value='Yes'  id='choice_2_63_0'    \/><label for='choice_2_63_0' id='label_2_63_0'>Yes<\/label><\/li><li class='gchoice_2_63_1'><input name='input_63' type='radio' value='No'  id='choice_2_63_1'    \/><label for='choice_2_63_1' id='label_2_63_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_64'  class='gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_64' >If yes, who was the Dr treating you?<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_2_64' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_2_95' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_95' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"5\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"5\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_5' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_5' class='gform_fields top_label form_sublabel_below description_below'><li id='field_2_89'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>NEXT OF KIN<\/h2><div class='gsection_description' id='gfield_description_2_89'>Not at the same address and telephone number - in case we cannot get hold of you confirming information.<\/div><\/li><li id='field_2_70'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Name<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_2_70'>\n                            \n                            <span id='input_2_70_3_container' class='name_first' >\n                                                    <input type='text' name='input_70.3' id='input_2_70_3' value='' aria-label='First name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_2_70_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_70_6_container' class='name_last' >\n                                                    <input type='text' name='input_70.6' id='input_2_70_6' value='' aria-label='Last name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_2_70_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_2_71'  class='gfield gf_left_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_71' >Relationship to patient<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_2_71' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_74'  class='gfield gf_middle_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_74' >Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_74' id='input_2_74' type='text' value='' class='medium'    aria-invalid=\"false\"  \/><\/div><\/li><li id='field_2_75'  class='gfield gf_right_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_75' >Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_75' id='input_2_75' type='text' value='' class='medium'    aria-invalid=\"false\"  \/><\/div><\/li><li id='field_2_78'  class='gfield gf_left_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_78' >Signed at<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_2_78' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_85'  class='gfield gf_middle_third field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >On this day<\/label><div id='input_2_85' class='ginput_container ginput_container_date'><div class='clear-multi'><div class='gfield_date_dropdown_month ginput_container ginput_container_date' id='input_2_85_1_container'><select name='input_85[]' id='input_2_85_1'   aria-label='Month'><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date' id='input_2_85_2_container'><select name='input_85[]' id='input_2_85_2'   aria-label='Day'><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date' id='input_2_85_3_container'><select name='input_85[]' id='input_2_85_3'   aria-label='Year'><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id='field_2_83'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_83' >Print Name<\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_2_83' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_97'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Client confirmation<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_97'><li class='gchoice_2_97_0'><input name='input_97' type='radio' value='I confirm that the details provided are correct'  id='choice_2_97_0'    \/><label for='choice_2_97_0' id='label_2_97_0'>I confirm that the details provided are correct<\/label><\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_97'>Once submitted you will receive an email with this completed form. Please print, sign and bring with you on your appointment date. Please make sure you bring all your supporting documents as per this page: https:\/\/www.chrisgreeff.com\/index.php\/whattoexpect\/<\/div><\/li><li id='field_2_101'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Important note on medical schemes<\/h2><div class='gsection_description' id='gfield_description_2_101'>KINDLY NOTE THAT- WE DO NOT DEAL WITH MEDICAL SCHEMES ON YOUR BEHALF. YOU ARE RESPONSIBLE TO SUBMIT THE ACCOUNT TO YOUR MEDICAL SCHEME.\nYOU ARE ALSO RESPONSIBLE TO ESTABLISH YOUR ORTHODONTIC BENEFITS WITH YOUR MEDICAL AID (KINDLY REFER TO PARAGRAPH OF THE FINANCIAL POLICY)<\/div><\/li><li id='field_2_102'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Important note on Payment of account.<\/h2><div class='gsection_description' id='gfield_description_2_102'>I, the undersigned, do hereby agree that: 1. Payment of the account in accordance with the tariff of charges prevailing in the practice shall be the responsibility of the undersigned\/patient. 2. In the event of the account not being settled timeously and in full by the undersigned\/patient and\/or the relevant medical aid, interest will be charged at a rate of 2% per month on the outstanding balance until that amount is settled in full. 3. I hereby declare that I am the legal guardian\/custodian of the above child and understand and accept the contract. 4. I undertake liability for all legal costs between attorney and client, as well as tracing and collection fees due. Should it be necessary to take legal action to recover and amount owing as a result of the treatment received by the above patient. 5 I further consent to your being entitled to obtain credit and related information concerning myself at any time and lodge, exchange and disclose such information with any Credit Bureau without any further notice to me.<\/div><\/li><li id='field_2_96'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_96' >Signature<span class='gfield_required'>*<\/span><\/label><div ><div id='input_2_96_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_2_96_valid' id='input_2_96_valid' \/><canvas id='input_2_96' width='300' height='180'><\/canvas><\/div><\/div><\/li><li id='field_2_103'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_103' >CAPTCHA<\/label><div id='input_2_103' class='ginput_container ginput_recaptcha' data-sitekey='6Ldr9rYqAAAAAI46ZO6RltdcL2KqNubRVr4e1Pd_'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/li>\n                            <\/ul><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_2' class='gform_previous_button button' value='Previous'  onclick='if(window[\"gf_submitting_2\"]){return false;}  window[\"gf_submitting_2\"]=true; 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