{"id":2588,"date":"2022-05-24T09:08:33","date_gmt":"2022-05-24T07:08:33","guid":{"rendered":"https:\/\/drhdejongh.co.za\/patient-practice-contract-information\/"},"modified":"2023-06-21T18:54:22","modified_gmt":"2023-06-21T16:54:22","slug":"patient-practice-contract-information","status":"publish","type":"page","link":"https:\/\/www.drhdejongh.co.za\/af-za\/patient-practice-contract-information\/","title":{"rendered":"Patient Practice Contract Information"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2588\" class=\"elementor elementor-2588 elementor-543\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-65e5b12 elementor-section-items-stretch elementor-section-height-min-height elementor-section-boxed elementor-section-height-default\" data-id=\"65e5b12\" data-element_type=\"section\" data-e-type=\"section\" 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class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t<div class=\"elementor-shape elementor-shape-bottom\" aria-hidden=\"true\" data-negative=\"true\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 1000 100\" preserveAspectRatio=\"none\">\n\t<path class=\"elementor-shape-fill\" d=\"M790.5,93.1c-59.3-5.3-116.8-18-192.6-50c-29.6-12.7-76.9-31-100.5-35.9c-23.6-4.9-52.6-7.8-75.5-5.3\n\tc-10.2,1.1-22.6,1.4-50.1,7.4c-27.2,6.3-58.2,16.6-79.4,24.7c-41.3,15.9-94.9,21.9-134,22.6C72,58.2,0,25.8,0,25.8V100h1000V65.3\n\tc0,0-51.5,19.4-106.2,25.7C839.5,97,814.1,95.2,790.5,93.1z\"\/>\n<\/svg>\t\t<\/div>\n\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-66 elementor-top-column elementor-element elementor-element-f182570\" data-id=\"f182570\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-9844abc elementor-widget elementor-widget-heading\" data-id=\"9844abc\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">Dr Heine De Jongh<\/h4>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-bf6de0f elementor-widget elementor-widget-heading\" data-id=\"bf6de0f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Patient Informasie<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-311ba9b\" data-id=\"311ba9b\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-aae2e1d elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"aae2e1d\" data-element_type=\"section\" data-e-type=\"section\" 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class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-cd941e8\" data-id=\"cd941e8\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-ef29bc6 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"ef29bc6\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-8763a36\" data-id=\"8763a36\" data-element_type=\"column\" data-e-type=\"column\" 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class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/af-za\/wp-json\/wp\/v2\/pages\/2588#gf_1' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_124\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Main Member Information<\/h3><\/div><div id=\"field_1_43\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_43'><span class='gform-field-label__text'>ID Number:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_1_43' type='text' value='' class='large'   tabindex='1'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_44\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_44'><span class='gform-field-label__text'>Surname:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_1_44' type='text' value='' class='large'   tabindex='2'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_45\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_45'><span class='gform-field-label__text'>Full Names:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_1_45' type='text' value='' class='large'   tabindex='3'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_46\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_46'><span class='gform-field-label__text'>Initials:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_1_46' type='text' value='' class='large'   tabindex='4'   aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_68\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-quarter gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Gender:<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_68'>\n\t\t\t<div class='gchoice gchoice_1_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Male'  id='choice_1_68_0' onchange='gformToggleRadioOther( this )'  tabindex='5'  \/>\n\t\t\t\t\t<label for='choice_1_68_0' id='label_1_68_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Female'  id='choice_1_68_1' onchange='gformToggleRadioOther( this )'  tabindex='6'  \/>\n\t\t\t\t\t<label for='choice_1_68_1' id='label_1_68_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_48\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_48'><span class='gform-field-label__text'>Title:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_1_48' type='text' value='' class='large'   tabindex='7'   aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_49\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Date of Birth:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_1_49' class='ginput_container ginput_complex gform-grid-row'>\n                                    <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_49_2_container'>\n                                        <input type='number' maxlength='2' name='input_49[]' id='input_1_49_2' value='' tabindex='8'  aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                        <label for='input_1_49_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                    <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_49_1_container'>\n                                    <input type='number' maxlength='2' name='input_49[]' id='input_1_49_1' value='' tabindex='9'  aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                    <label for='input_1_49_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                               <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_49_3_container'>\n                                    <input type='number' maxlength='4' name='input_49[]' id='input_1_49_3' value='' tabindex='10'  aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                    <label for='input_1_49_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                               <\/div>\n                            <\/div><\/fieldset><div id=\"field_1_70\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_70'><span class='gform-field-label__text'>Employer:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_1_70' type='text' value='' class='large'   tabindex='11'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_71\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_71'><span class='gform-field-label__text'>Cell Number:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_71' id='input_1_71' type='tel' value='' class='large' tabindex='12' placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_1_74\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_74'><span class='gform-field-label__text'>Home Number:<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_74' id='input_1_74' type='tel' value='' class='large' tabindex='13' placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_1_73\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_73'><span class='gform-field-label__text'>Work Number:<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_73' id='input_1_73' type='tel' value='' class='large' tabindex='14' placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_1_72\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_72'><span class='gform-field-label__text'>Fax Number:<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_72' id='input_1_72' type='tel' value='' class='large' tabindex='15' placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_1_75\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_75'><span class='gform-field-label__text'>Email Address:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_75' id='input_1_75' type='email' value='' class='large' tabindex='16'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_1_77\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Postal Address:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_1_77' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_77_1_container' >\n                                        <label for='input_1_77_1' id='input_1_77_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_77.1' id='input_1_77_1' value='' tabindex='17'   aria-required='true'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_77_2_container' >\n                                        <label for='input_1_77_2' id='input_1_77_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_77.2' id='input_1_77_2' value='' tabindex='18'    aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_77_3_container' >\n                                    <label for='input_1_77_3' id='input_1_77_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_77.3' id='input_1_77_3' value='' tabindex='19'   aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_77_4_container' >\n                                        <label for='input_1_77_4' id='input_1_77_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                        <input type='text' name='input_77.4' id='input_1_77_4' value='' tabindex='21'     aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_77_5_container' >\n                                    <label for='input_1_77_5' id='input_1_77_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_77.5' id='input_1_77_5' value='' tabindex='22'   aria-required='true'    \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_77_6_container' >\n                                        <label for='input_1_77_6' id='input_1_77_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                        <select name='input_77.6' id='input_1_77_6' tabindex='23'  aria-required='true'    ><option value='' ><\/option><option value='AF' >Afghanistan<\/option><option value='AX' >\u00c5land Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='CV' >Cabo Verde<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Democratic Republic of the<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='CI' >C\u00f4te d&#039;Ivoire<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czechia<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >Eswatini<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='VA' >Holy See<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='KP' >Korea, Democratic People&#039;s Republic of<\/option><option value='KR' >Korea, Republic of<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Lao People&#039;s Democratic Republic<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='MK' >North Macedonia<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PS' >Palestine, State of<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='RE' >R\u00e9union<\/option><option value='RO' >Romania<\/option><option value='RU' >Russian Federation<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='SH' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='MF' >Saint Martin<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SX' >Sint Maarten<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' selected='selected'>South Africa<\/option><option value='GS' >South Georgia and the South Sandwich Islands<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria Arab Republic<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania, the United Republic of<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >T\u00fcrkiye<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom<\/option><option value='US' >United States<\/option><option value='UY' >Uruguay<\/option><option value='UM' >US Minor Outlying Islands<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Viet Nam<\/option><option value='VG' >Virgin Islands, British<\/option><option value='VI' >Virgin Islands, U.S.<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option> <\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_1_78\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Physical Address:<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_1_78' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_78_1_container' >\n                                        <label for='input_1_78_1' id='input_1_78_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_78.1' id='input_1_78_1' value='' tabindex='24'   aria-required='false'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_78_2_container' >\n                                        <label for='input_1_78_2' id='input_1_78_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_78.2' id='input_1_78_2' value='' tabindex='25'    aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_78_3_container' >\n                                    <label for='input_1_78_3' id='input_1_78_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_78.3' id='input_1_78_3' value='' tabindex='26'   aria-required='false'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_78_4_container' >\n                                        <label for='input_1_78_4' id='input_1_78_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                        <input type='text' name='input_78.4' id='input_1_78_4' value='' tabindex='28'     aria-required='false'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_78_5_container' >\n                                    <label for='input_1_78_5' id='input_1_78_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_78.5' id='input_1_78_5' value='' tabindex='29'   aria-required='false'    \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_78_6_container' >\n                                        <label for='input_1_78_6' id='input_1_78_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                        <select name='input_78.6' id='input_1_78_6' tabindex='30'  aria-required='false'    ><option value='' ><\/option><option value='AF' >Afghanistan<\/option><option value='AX' >\u00c5land Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='CV' >Cabo Verde<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Democratic Republic of the<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='CI' >C\u00f4te d&#039;Ivoire<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czechia<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >Eswatini<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='VA' >Holy See<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='KP' >Korea, Democratic People&#039;s Republic of<\/option><option value='KR' >Korea, Republic of<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Lao People&#039;s Democratic Republic<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='MK' >North Macedonia<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PS' >Palestine, State of<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='RE' >R\u00e9union<\/option><option value='RO' >Romania<\/option><option value='RU' >Russian Federation<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='SH' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='MF' >Saint Martin<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SX' >Sint Maarten<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' selected='selected'>South Africa<\/option><option value='GS' >South Georgia and the South Sandwich Islands<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria Arab Republic<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania, the United Republic of<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >T\u00fcrkiye<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom<\/option><option value='US' >United States<\/option><option value='UY' >Uruguay<\/option><option value='UM' >US Minor Outlying Islands<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Viet Nam<\/option><option value='VG' >Virgin Islands, British<\/option><option value='VI' >Virgin Islands, U.S.<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option> <\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_79\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_79'><span class='gform-field-label__text'>Medical Scheme:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_1_79' type='text' value='' class='large'   tabindex='31'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_80\" class=\"gfield gfield--type-text gfield--width-three-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_80'><span class='gform-field-label__text'>Plan\/Option:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_1_80' type='text' value='' class='large'   tabindex='32'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-quarter gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Gap Cover:<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_81'>\n\t\t\t<div class='gchoice gchoice_1_81_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Yes'  id='choice_1_81_0' onchange='gformToggleRadioOther( this )'  tabindex='33'  \/>\n\t\t\t\t\t<label for='choice_1_81_0' id='label_1_81_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_81_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='No'  id='choice_1_81_1' onchange='gformToggleRadioOther( this )'  tabindex='34'  \/>\n\t\t\t\t\t<label for='choice_1_81_1' id='label_1_81_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_82\" class=\"gfield gfield--type-text gfield--width-three-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_82'><span class='gform-field-label__text'>Member No.:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_1_82' type='text' value='' class='large'   tabindex='35'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_83\" class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_83'><span class='gform-field-label__text'>Main Member Dep Code:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_1_83' type='text' value='' class='large'   tabindex='36'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <button type='button' id='gform_next_button_1_84' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' tabindex='37'>Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-84' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_125\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Patient Information<\/h3><\/div><div id=\"field_1_85\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_85'><span class='gform-field-label__text'>ID Number:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_1_85' type='text' value='' class='large'   tabindex='38'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_86\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_86'><span class='gform-field-label__text'>Surname:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_1_86' type='text' value='' class='large'   tabindex='39'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_87\" class=\"gfield gfield--type-text gfield--width-three-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_87'><span class='gform-field-label__text'>Full Names:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_1_87' type='text' value='' class='large'   tabindex='40'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_88\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_88'><span class='gform-field-label__text'>Nick Name:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_1_88' type='text' value='' class='large'   tabindex='41'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_89\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_89'><span class='gform-field-label__text'>Initials:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_1_89' type='text' value='' class='large'   tabindex='42'   aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_90\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-quarter gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Gender:<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_90'>\n\t\t\t<div class='gchoice gchoice_1_90_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='Male'  id='choice_1_90_0' onchange='gformToggleRadioOther( this )'  tabindex='43'  \/>\n\t\t\t\t\t<label for='choice_1_90_0' id='label_1_90_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_90_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='Female'  id='choice_1_90_1' onchange='gformToggleRadioOther( this )'  tabindex='44'  \/>\n\t\t\t\t\t<label for='choice_1_90_1' id='label_1_90_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_91\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_91'><span class='gform-field-label__text'>Title:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_91' id='input_1_91' type='text' value='' class='large'   tabindex='45'   aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_92\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Date of Birth:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_1_92' class='ginput_container ginput_complex gform-grid-row'>\n                                    <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_92_2_container'>\n                                        <input type='number' maxlength='2' name='input_92[]' id='input_1_92_2' value='' tabindex='46'  aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                        <label for='input_1_92_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                    <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_92_1_container'>\n                                    <input type='number' maxlength='2' name='input_92[]' id='input_1_92_1' value='' tabindex='47'  aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                    <label for='input_1_92_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                               <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_92_3_container'>\n                                    <input type='number' maxlength='4' name='input_92[]' id='input_1_92_3' value='' tabindex='48'  aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                    <label for='input_1_92_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                               <\/div>\n                            <\/div><\/fieldset><div id=\"field_1_93\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_93'><span class='gform-field-label__text'>Cell Number:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_93' id='input_1_93' type='tel' value='' class='large' tabindex='49' placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><fieldset id=\"field_1_94\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Use this number for appointments \/ test results:<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_94'>\n\t\t\t<div class='gchoice gchoice_1_94_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='Yes'  id='choice_1_94_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_94\" tabindex='50'  \/>\n\t\t\t\t\t<label for='choice_1_94_0' id='label_1_94_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_94_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='No'  id='choice_1_94_1' onchange='gformToggleRadioOther( this )'  tabindex='51'  \/>\n\t\t\t\t\t<label for='choice_1_94_1' id='label_1_94_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_94'>Main member's Cell Phone number will be used if above is No<\/div><\/fieldset><div id=\"field_1_95\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_95'><span class='gform-field-label__text'>Home Number:<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_95' id='input_1_95' type='tel' value='' class='large' tabindex='52' placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_1_98\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_98'><span class='gform-field-label__text'>Work Number:<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_98' id='input_1_98' type='tel' value='' class='large' tabindex='53' placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_1_96\" class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_96'><span class='gform-field-label__text'>Email Address:<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_96' id='input_1_96' type='email' value='' class='large' tabindex='54'    aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_97\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_97'><span class='gform-field-label__text'>Occupation:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_1_97' type='text' value='' class='large'   tabindex='55'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_100\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_100'><span class='gform-field-label__text'>Marital Status:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_1_100' type='text' value='' class='large'   tabindex='56'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_99\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_99'><span class='gform-field-label__text'>Relationship to Main Member:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_1_99' type='text' value='' class='large'   tabindex='57'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_104\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_104'><span class='gform-field-label__text'>Patient Dependant Code:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_1_104' type='text' value='' class='large'   tabindex='58'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_101\" class=\"gfield gfield--type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_101'><span class='gform-field-label__text'>Age (years):<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_101' id='input_1_101' type='number' step='any'   value='' class='large' tabindex='59'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_102\" class=\"gfield gfield--type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_102'><span class='gform-field-label__text'>Height (cm):<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_102' id='input_1_102' type='number' step='any'   value='' class='large' tabindex='60'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_103\" class=\"gfield gfield--type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_103'><span class='gform-field-label__text'>Weight (kg):<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_103' id='input_1_103' type='number' step='any'   value='' class='large' tabindex='61'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_105\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_105'><span class='gform-field-label__text'>Referring Dr:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_1_105' type='text' value='' class='large'   tabindex='62'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_107\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_107'><span class='gform-field-label__text'>Tel No.:<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_107' id='input_1_107' type='tel' value='' class='large' tabindex='63' placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_1_106\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_106'><span class='gform-field-label__text'>GP:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_106' id='input_1_106' type='text' value='' class='large'   tabindex='64'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_108\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_108'><span class='gform-field-label__text'>Tel No.:<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_108' id='input_1_108' type='tel' value='' class='large' tabindex='65' placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_1_109' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' tabindex='66'>Previous<\/button> <button type='button' id='gform_next_button_1_109' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' tabindex='67'>Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-109' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_126\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Next of Kin<\/h3><div class='gsection_description' id='gfield_description_1_126'>Not from the same physical address<\/div><\/div><div id=\"field_1_110\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_110'><span class='gform-field-label__text'>Initials:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_1_110' type='text' value='' class='large'   tabindex='68'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_112\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_112'><span class='gform-field-label__text'>Title:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_112' id='input_1_112' type='text' value='' class='large'   tabindex='69'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_111\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_111'><span class='gform-field-label__text'>Surname:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_111' id='input_1_111' type='text' value='' class='large'   tabindex='70'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_113\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_113'><span class='gform-field-label__text'>Full Names:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_1_113' type='text' value='' class='large'   tabindex='71'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_114\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_114'><span class='gform-field-label__text'>Cell Number:<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_114' id='input_1_114' type='tel' value='' class='large' tabindex='72' placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_1_115\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_115'><span class='gform-field-label__text'>Relationship to Patient:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_115' id='input_1_115' type='text' value='' class='large'   tabindex='73'   aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_116\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Consent<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_116.1' id='input_1_116_1' type='checkbox' value='1' tabindex='74'  aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_116_1' ><span class='gform-field-label__text'>Hereby I confirm that the information I supplied is true and I am responsible for any false information provided<\/span><\/label><input type='hidden' name='input_116.2' value='Hereby I confirm that the information I supplied is true and I am responsible for any false information provided' class='gform_hidden' \/><input type='hidden' name='input_116.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_1_118\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_118'><span class='gform-field-label__text'>Name:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_1_118' type='text' value='' class='large'   tabindex='75'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_127\" class=\"gfield gfield--type-signature gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_127'><span class='gform-field-label__text'>Signature<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_127' id='input_1_127_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_127_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_1_127' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/www.drhdejongh.co.za\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_1_127_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_1_127_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_1_127_data' name='input_1_127_data' value=''><\/div><\/div><div id=\"field_1_117\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_117'><span class='gform-field-label__text'>Date of Signature:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='dd\/mm\/yyyy'\n\t\t\t\t\tid='input_1_117'\n\t\t\t\t\tclass='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_117'\n\t\t\t\t\tvalue='26\/08\/2026'\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\ttabindex='76' \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_1_117' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_1_117' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_1_117' aria-label='Date of Signature:: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><button type='submit' id='gform_previous_button_1' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' tabindex='77'>Previous<\/button> <button type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' tabindex='78'>Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='ZAR' value='gHe+1v+eq4v8WYSgfjMyhJBqghqeGST8YlkiR46rTXwALOy7YckAkp8UCNArswVheeQNBbztOz94AZ9ahziG7VoOP6knCGCM3fZDbFJYtMr3eEA=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='2' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n             <\/div><\/div>\n                        <\/form>\n                        <\/div>\n<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-bbdd40f elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"bbdd40f\" data-element_type=\"section\" data-e-type=\"section\" 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class=\"elementor-shape elementor-shape-top\" aria-hidden=\"true\" data-negative=\"true\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 1000 100\" preserveAspectRatio=\"none\">\n\t<path class=\"elementor-shape-fill\" d=\"M790.5,93.1c-59.3-5.3-116.8-18-192.6-50c-29.6-12.7-76.9-31-100.5-35.9c-23.6-4.9-52.6-7.8-75.5-5.3\n\tc-10.2,1.1-22.6,1.4-50.1,7.4c-27.2,6.3-58.2,16.6-79.4,24.7c-41.3,15.9-94.9,21.9-134,22.6C72,58.2,0,25.8,0,25.8V100h1000V65.3\n\tc0,0-51.5,19.4-106.2,25.7C839.5,97,814.1,95.2,790.5,93.1z\"\/>\n<\/svg>\t\t<\/div>\n\t\t\t\t<div class=\"elementor-shape elementor-shape-bottom\" aria-hidden=\"true\" data-negative=\"true\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 1000 100\" preserveAspectRatio=\"none\">\n\t<path class=\"elementor-shape-fill\" d=\"M790.5,93.1c-59.3-5.3-116.8-18-192.6-50c-29.6-12.7-76.9-31-100.5-35.9c-23.6-4.9-52.6-7.8-75.5-5.3\n\tc-10.2,1.1-22.6,1.4-50.1,7.4c-27.2,6.3-58.2,16.6-79.4,24.7c-41.3,15.9-94.9,21.9-134,22.6C72,58.2,0,25.8,0,25.8V100h1000V65.3\n\tc0,0-51.5,19.4-106.2,25.7C839.5,97,814.1,95.2,790.5,93.1z\"\/>\n<\/svg>\t\t<\/div>\n\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-f2a1d82\" data-id=\"f2a1d82\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-fc130e2\" data-id=\"fc130e2\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-18b8f91 elementor-widget elementor-widget-heading\" data-id=\"18b8f91\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">'n <b>verbeterde<\/b><br>\nlewensgehalte<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-94a11c2 elementor-widget elementor-widget-text-editor\" data-id=\"94a11c2\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Lorem ipsum dolor sit amet, consetetur sadipscing elitr, sed diam nonumy eirmod tempor invidunt ut labore et dolore magna aliquyam erat, sed diam voluptua. Lorem ipsum dolor sit amet, consetetur sadipscing elitr. <\/p>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-de88bbb elementor-widget__width-auto btn1 elementor-widget elementor-widget-button\" data-id=\"de88bbb\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"#\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-long-arrow-alt-right\"><\/i>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Hoe kan ons help?<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-5b7a904 elementor-widget__width-auto btn2 elementor-widget elementor-widget-button\" data-id=\"5b7a904\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"#\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-long-arrow-alt-right\"><\/i>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">kontak ons<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Dr Heine De Jongh Patient Informasie &quot;*&quot; indicates required fields Main Member Information ID Number:* Surname:* Full Names:* Initials: Gender: Male Female Title: Date of Birth:* Day Month Year Employer: Cell Number:*Home Number:Work Number:Fax Number:Email Address:* Postal Address:* Street Address Address Line 2 City State \/ Province \/ Region ZIP \/ Postal Code Country AfghanistanAlbaniaAlgeriaAmerican [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-2588","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.drhdejongh.co.za\/af-za\/wp-json\/wp\/v2\/pages\/2588","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.drhdejongh.co.za\/af-za\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.drhdejongh.co.za\/af-za\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.drhdejongh.co.za\/af-za\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.drhdejongh.co.za\/af-za\/wp-json\/wp\/v2\/comments?post=2588"}],"version-history":[{"count":0,"href":"https:\/\/www.drhdejongh.co.za\/af-za\/wp-json\/wp\/v2\/pages\/2588\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.drhdejongh.co.za\/af-za\/wp-json\/wp\/v2\/media?parent=2588"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}