{"id":184,"date":"2023-01-02T14:37:43","date_gmt":"2023-01-02T07:37:43","guid":{"rendered":"http:\/\/localhost\/telemed\/"},"modified":"2023-01-25T23:06:29","modified_gmt":"2023-01-25T16:06:29","slug":"telemed","status":"publish","type":"page","link":"https:\/\/ppat.clinic\/en\/telemed","title":{"rendered":"Telemed"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script><script type=\"text\/javascript\">\n        var gfafPrePopfield = function(formid, fromfield, tofield, inputid) {\n            if (!inputid) {\n                document.getElementById(\"input_\" + formid + \"_\" + tofield).value = document.getElementById(\"input_\" + formid + \"_\" + fromfield).value ? document.getElementById(\"input_\" + formid + \"_\" + fromfield).value : \"\";\n            } else {\n                if (document.getElementById(\"input_\" + formid + \"_\" + tofield + \"_\" + inputid)) {\n                    document.getElementById(\"input_\" + formid + \"_\" + tofield + \"_\" + inputid).value = document.getElementById(\"input_\" + formid + \"_\" + fromfield + \"_\" + inputid).value ? document.getElementById(\"input_\" + formid + \"_\" + fromfield + \"_\" + inputid).value : \"\";\n                }\n            }\n        }\n    <\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/en\/wp-json\/wp\/v2\/pages\/184' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_202\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_202\"><h3 class=\"gsection_title\">Basic Information<\/h3><\/div><div id=\"field_1_1\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_1\"><label class='gfield_label gform-field-label' for='input_1_1' >Title<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_1' id='input_1_1' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='2' >Miss<\/option><option value='1' >Mrs.<\/option><option value='6' >Child<\/option><option value='7' >Dr.<\/option><\/select><\/div><\/div><div id=\"field_1_2\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_2\"><label class='gfield_label gform-field-label' for='input_1_2' >name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_1_2' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_3\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\"><label class='gfield_label gform-field-label' for='input_1_3' >Lastname<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_6\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible gfafnumericonly\"  data-field-class=\"gfafnumericonly\" data-js-reload=\"field_1_6\"><label class='gfield_label gform-field-label' for='input_1_6' >Mobile Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' onchange='gfafPrePopfield(1, 6, 7, false)' id='input_1_6' onkeypress=\"return event.charCode >= 48 &#038;&#038; event.charCode <= 57\" oninput=\"this.value=this.value.replace(\/[^0-9]\/g,'');\" \" type='text' value='' class='large' maxlength='10'   placeholder='**For SMS Notification' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_4\"  class=\"gfield gfield--type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_1_4\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_4' >Sex<\/label><div class='ginput_container ginput_container_select'><select name='input_4' id='input_1_4' class='large gfield_select'     aria-invalid=\"false\" ><option value='F' selected='selected'>Female<\/option><\/select><\/div><\/div><div id=\"field_1_5\"  class=\"gfield gfield--type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_1_5\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_5' >pmseu<\/label><div class='ginput_container ginput_container_select'><select name='input_5' id='input_1_5' class='large gfield_select'     aria-invalid=\"false\" ><option value='4' >4<\/option><\/select><\/div><\/div><div id=\"field_1_7\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_1_7\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_7' >Email<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_8\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\"><label class='gfield_label gform-field-label' for='input_1_8' >Passport<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_8' id='input_1_8' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='1' >ID Card<\/option><option value='2' >Passport No.<\/option><option value='3' >No<\/option><\/select><\/div><\/div><div id=\"field_1_9\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\"><label class='gfield_label gform-field-label' for='input_1_9' >Passport No.<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_10\"  class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\"><legend class='gfield_label gform-field-label'  >DOB<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_1_10' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_1_10_2_container'><select name='input_10[]' id='input_1_10_2'   aria-required='true'  ><option value=''>DD<\/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_month ginput_container ginput_container_date gform-grid-col' id='input_1_10_1_container'><select name='input_10[]' id='input_1_10_1'   aria-required='true'  ><option value=''>MM<\/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_year ginput_container ginput_container_date gform-grid-col' id='input_1_10_3_container'><select name='input_10[]' id='input_1_10_3'   aria-required='true'  ><option value=''>YYYY<\/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><\/fieldset><div id=\"field_1_208\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_208\"><label class='gfield_label gform-field-label' for='input_1_208' >Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_208' id='input_1_208' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_203\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_203\"><h3 class=\"gsection_title\">Basic information<\/h3><\/div><div id=\"field_1_12\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible gfafnumericonly\"  data-field-class=\"gfafnumericonly\" data-js-reload=\"field_1_12\"><label class='gfield_label gform-field-label' for='input_1_12' >Weight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' onkeypress=\"return event.charCode >= 48 &#038;&#038; event.charCode <= 57\" oninput=\"this.value=this.value.replace(\/[^0-9]\/g,'');\" \" type='text' value='' class='large' maxlength='3'   placeholder='Please enter number only.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_13\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible gfafnumericonly\"  data-field-class=\"gfafnumericonly\" data-js-reload=\"field_1_13\"><label class='gfield_label gform-field-label' for='input_1_13' >Height<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' onkeypress=\"return event.charCode >= 48 &#038;&#038; event.charCode <= 57\" oninput=\"this.value=this.value.replace(\/[^0-9]\/g,'');\" \" type='text' value='' class='large' maxlength='3'   placeholder='Please enter number only.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_14\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_14\"><label class='gfield_label gform-field-label' for='input_1_14' >Education<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_1_14' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='1' >Primary School<\/option><option value='2' >Secondary School<\/option><option value='3' >High School<\/option><option value='4' >Diploma Degree<\/option><option value='5' >High Diploma Degree<\/option><option value='6' >Bachelor Degrees<\/option><option value='7' >Upper than Bachelor Degrees<\/option><\/select><\/div><\/div><div id=\"field_1_15\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_15\"><label class='gfield_label gform-field-label' for='input_1_15' >occupation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_15' id='input_1_15' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='1' >Farmer<\/option><option value='2' >government officer<\/option><option value='3' >trade<\/option><option value='4' >fisherman<\/option><option value='5' >personal business<\/option><option value='6' >students<\/option><option value='7' >company employee<\/option><option value='8' >state enterprise employees<\/option><option value='9' >maid<\/option><option value='10' >general employee<\/option><option value='11' >government employees<\/option><option value='12' >unemployed<\/option><\/select><\/div><\/div><div id=\"field_1_17\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_17\"><label class='gfield_label gform-field-label' for='input_1_17' >marital status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_1_17' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='1' >single<\/option><option value='2' >married<\/option><option value='3' >divorced\/separated<\/option><option value='4' >other<\/option><\/select><\/div><\/div><div id=\"field_1_18\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_18\"><label class='gfield_label gform-field-label' for='input_1_18' >nationality<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_1_18' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='1' >Thai<\/option><option value='2' >Myanmar<\/option><option value='3' >Cambodia<\/option><option value='4' >Laos<\/option><option value='5' >Vietnam<\/option><option value='6' >China<\/option><option value='7' >other<\/option><\/select><\/div><\/div><div id=\"field_1_204\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_204\"><h3 class=\"gsection_title\">address for drug delivery<\/h3><\/div><div id=\"field_1_19\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_19\"><label class='gfield_label gform-field-label' for='input_1_19' >region<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_1_19' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Region of current residence<\/option><option value='1' >the North<\/option><option value='2' >Northeast<\/option><option value='3' >Central<\/option><option value='4' >Eastern<\/option><option value='5' >western region<\/option><option value='6' >South<\/option><option value='7' >abroad<\/option><\/select><\/div><\/div><div id=\"field_1_20\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_20\"><label class='gfield_label gform-field-label' for='input_1_20' >current address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_1_20' type='text' value='' class='large'    placeholder='Please specify the house number, Moo No. (Clear)' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_21\"  class=\"gfield gfield--type-text gfield--width-full #billing_address_2 gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_21\"><label class='gfield_label gform-field-label' for='input_1_21' >district<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_1_21' type='text' value='' class='large'    placeholder='Type the name of the district and press select information' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_22\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\"><label class='gfield_label gform-field-label' for='input_1_22' >district<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_1_22' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_23\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_23\"><label class='gfield_label gform-field-label' for='input_1_23' >province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_1_23' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_24\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible gfafnumericonly\"  data-field-class=\"gfafnumericonly\" data-js-reload=\"field_1_24\"><label class='gfield_label gform-field-label' for='input_1_24' >zip code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_1_24' onkeypress=\"return event.charCode >= 48 &#038;&#038; event.charCode <= 57\" oninput=\"this.value=this.value.replace(\/[^0-9]\/g,'');\" \" type='text' value='' class='large' maxlength='5'    aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_205\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_205\"><h3 class=\"gsection_title\">Emergency Contact<\/h3><\/div><div id=\"field_1_25\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\"><label class='gfield_label gform-field-label' for='input_1_25' >contact name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_1_25' type='text' value='' class='large'    placeholder='*use in case of emergency' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_26\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\"><label class='gfield_label gform-field-label' for='input_1_26' >Contact&#039;s last name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_1_26' type='text' value='' class='large'    placeholder='*use in case of emergency' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_27\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible gfafnumericonly\"  data-field-class=\"gfafnumericonly\" data-js-reload=\"field_1_27\"><label class='gfield_label gform-field-label' for='input_1_27' >Mobile Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_1_27' onkeypress=\"return event.charCode >= 48 &#038;&#038; event.charCode <= 57\" oninput=\"this.value=this.value.replace(\/[^0-9]\/g,'');\" \" type='text' value='' class='large' maxlength='10'   placeholder='*use in case of emergency' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_206\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_206\"><h3 class=\"gsection_title\">medical information<\/h3><\/div><div id=\"field_1_28\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_28\"><label class='gfield_label gform-field-label' for='input_1_28' >Do you have a history of drug allergies?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_28' id='input_1_28' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='N' >do not have<\/option><option value='Y' >have<\/option><\/select><\/div><\/div><div id=\"field_1_29\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_29\"><label class='gfield_label gform-field-label' for='input_1_29' >a history of drug allergies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_1_29' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_30\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\"><label class='gfield_label gform-field-label' for='input_1_30' >health history and regular medications<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_1_30' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_31\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_31\"><label class='gfield_label gform-field-label' for='input_1_31' >How many times is it a pregnancy?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_31' id='input_1_31' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='1st time' >1st time<\/option><option value='2nd time' >2nd time<\/option><option value='3rd time' >3rd time<\/option><option value='4th time' >4th time<\/option><option value='5th time' >5th time<\/option><\/select><\/div><\/div><div id=\"field_1_32\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_32\"><label class='gfield_label gform-field-label' for='input_1_32' >having children included<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_1_32' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='0' >do not have<\/option><option value='1' >1 person<\/option><option value='2' >2 people<\/option><option value='3' >3 people<\/option><option value='4' >4 people<\/option><option value='5' >5 people<\/option><option value='more than 5 people' >more than 5 people<\/option><\/select><\/div><\/div><div id=\"field_1_35\"  class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_35\"><label class='gfield_label gform-field-label' for='input_1_35' >Youngest child age (years)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_35' id='input_1_35' type='number' step='any'   value='' class='large'    placeholder='Enter only year numbers' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_36\"  class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\"><label class='gfield_label gform-field-label' for='input_1_36' >(month)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_36' id='input_1_36' type='number' step='any'   value='' class='large'    placeholder='Enter only month numbers' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_33\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_33\"><label class='gfield_label gform-field-label' for='input_1_33' >being a woman (person)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_33' id='input_1_33' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='0' >0 people<\/option><option value='1 person' >1 person<\/option><option value='2 people' >2 people<\/option><option value='3 people' >3 people<\/option><option value='4 people' >4 people<\/option><option value='5 people' >5 people<\/option><option value='more than 5 people' >more than 5 people<\/option><\/select><\/div><\/div><div id=\"field_1_34\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\"><label class='gfield_label gform-field-label' for='input_1_34' >male (person)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_34' id='input_1_34' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='0' >0 people<\/option><option value='1 person' >1 person<\/option><option value='2 people' >2 people<\/option><option value='3 people' >3 people<\/option><option value='4 people' >4 people<\/option><option value='5 people' >5 people<\/option><option value='more than 5 people' >more than 5 people<\/option><\/select><\/div><\/div><div id=\"field_1_37\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_37\"><label class='gfield_label gform-field-label' for='input_1_37' >method of childbirth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_37' id='input_1_37' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='1' >natural birth<\/option><option value='2' >Caesarean section<\/option><option value='3' >ever had an ectopic pregnancy<\/option><\/select><\/div><\/div><fieldset id=\"field_1_38\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_38\"><legend class='gfield_label gform-field-label'  >Have you had a miscarriage before?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_38'>\n\t\t\t<div class='gchoice gchoice_1_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='ever'  id='choice_1_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_38_0' id='label_1_38_0' class='gform-field-label gform-field-label--type-inline'>ever<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='never'  id='choice_1_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_38_1' id='label_1_38_1' class='gform-field-label gform-field-label--type-inline'>never<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_39\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_39\"><label class='gfield_label gform-field-label' for='input_1_39' >How many times have you had an abortion?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_39' id='input_1_39' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='1 time' >1 time<\/option><option value='2 times' >2 times<\/option><option value='3 times' >3 times<\/option><option value='4 times' >4 times<\/option><option value='5 times' >5 times<\/option><\/select><\/div><\/div><div id=\"field_1_40\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_40\"><label class='gfield_label gform-field-label' for='input_1_40' >How is it a miscarriage?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_40' id='input_1_40' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='spontaneous abortion' >spontaneous abortion<\/option><option value='Safe Abortion' >Safe Abortion<\/option><option value='Spontaneous abortion and termination of pregnancy' >Spontaneous abortion and termination of pregnancy<\/option><\/select><\/div><\/div><div id=\"field_1_41\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_41\"><label class='gfield_label gform-field-label' for='input_1_41' >What is your gestational age (weeks)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_41' id='input_1_41' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='4 to 12 weeks' >4 to 12 weeks<\/option><option value='more than 12 weeks' >more than 12 weeks<\/option><\/select><\/div><\/div><div id=\"field_1_42\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_42\"><label class='gfield_label gform-field-label' for='input_1_42' >More than 12 weeks (please specify gestational age)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_1_42' type='text' value='' class='large'    placeholder='Please specify gestational age' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_43\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_43\"><label class='gfield_label gform-field-label' for='input_1_43' >cause of pregnancy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_43' id='input_1_43' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='1' >contraceptive failure<\/option><option value='2' >Using emergency contraceptives was raped.<\/option><option value='3' >count the days wrong<\/option><option value='4' >not contraceptive<\/option><option value='5' >forget to take birth control pills<\/option><option value='6' >cum outside<\/option><option value='7' >other<\/option><\/select><\/div><\/div><div id=\"field_1_44\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_44\"><label class='gfield_label gform-field-label' for='input_1_44' >Other reasons, please specify.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_1_44' type='text' value='' class='large'    placeholder='Other reasons, please specify clearly.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_45\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_45\"><label class='gfield_label gform-field-label' for='input_1_45' >The reason for the termination of pregnancy is<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_45' id='input_1_45' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='1' >Pregnancy is a career hurdle.<\/option><option value='2' >family problems<\/option><option value='3' >Pregnant with someone who is not your husband<\/option><option value='4' >raped<\/option><option value='5' >financial problems<\/option><option value='6' >health problems<\/option><option value='7' >The man has a family<\/option><option value='8' >men are not responsible<\/option><option value='9' >having too many children<\/option><option value='10' >having enough children<\/option><option value='11' >having problems with male relatives<\/option><option value='12' >have a new husband<\/option><option value='13' >unmarried<\/option><option value='14' >not yet graduated<\/option><option value='15' >Divorce or break up with husband or male friend<\/option><option value='16' >other<\/option><\/select><\/div><\/div><div id=\"field_1_46\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_46\"><label class='gfield_label gform-field-label' for='input_1_46' >Other reasons, please specify.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_1_46' type='text' value='' class='large'    placeholder='Other reasons, please specify clearly.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_209\"  class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_209\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Confirm Service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_209.1' id='input_1_209_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_209_1' >Please click to confirm the service and accept all terms and conditions from PPAT Telemed system.<\/label><input type='hidden' name='input_209.2' value='Please click to confirm the service and accept all terms and conditions from PPAT Telemed system.' class='gform_hidden' \/><input type='hidden' name='input_209.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> \n         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