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437.288px;\"\u003E\r\n\u003Ctable\u003E\r\n\u003Ctbody\u003E\r\n\u003Ctr\u003E\r\n\u003Ctd\u003E\u003Cspan style=\"color: #a5a8b3; font-size: 12px; font-weight: 400; line-height: 20px;\"\u003EDuration\u003C\u002Fspan\u003E\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr\u003E\r\n\u003Ctd\u003E\u003Cspan style=\"color: #2b3245; font-size: 14px; font-weight: 400; line-height: 20px;\"\u003E{pleaseSelect:duration}\u003C\u002Fspan\u003E\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003C\u002Ftbody\u003E\r\n\u003C\u002Ftable\u003E\r\n\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr style=\"vertical-align: text-top;\"\u003E\r\n\u003Ctd style=\"width: 46.9125px;\"\u003E\u003Cimg style=\"margin-right: 5px;\" src=\"https:\u002F\u002Femails.jotform.com\u002Fimg\u002Fappointment\u002Ftimezone.png?v=1.0\" alt=\"appointment icon\" width=\"14\" \u002F\u003E\u003C\u002Ftd\u003E\r\n\u003Ctd style=\"width: 437.288px;\"\u003E\r\n\u003Ctable\u003E\r\n\u003Ctbody\u003E\r\n\u003Ctr\u003E\r\n\u003Ctd\u003E\u003Cspan style=\"color: #a5a8b3; font-size: 12px; font-weight: 400; line-height: 20px;\"\u003ETimezone\u003C\u002Fspan\u003E\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr\u003E\r\n\u003Ctd\u003E\u003Cspan style=\"color: #2b3245; font-size: 14px; font-weight: 400; line-height: 20px;\"\u003E{pleaseSelect:timezone}\u003C\u002Fspan\u003E\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003C\u002Ftbody\u003E\r\n\u003C\u002Ftable\u003E\r\n\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003C\u002Ftbody\u003E\r\n\u003C\u002Ftable\u003E\r\n\u003C\u002Fcenter\u003E\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003C\u002Ftbody\u003E\r\n\u003C\u002Ftable\u003E\r\n\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr\u003E\r\n\u003Ctd height=\"18\"\u003E&nbsp;\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr\u003E\r\n\u003Ctd\u003E\r\n\u003Ctable class=\"jmTable\" style=\"min-width: 480px; max-width: 720px; width: 100%; background-color: #fff; text-align: center; font-size: 14px; line-height: 16px;\" width=\"100%\" cellspacing=\"0\" cellpadding=\"0\"\u003E\r\n\u003Ctbody\u003E\r\n\u003Ctr\u003E\r\n\u003Ctd style=\"width: 100%; max-width: 100%; min-width: 100%;\"\u003EAdd to&nbsp; \u003Ca href=\"{googleCalendarLink:pleaseSelect}\"\u003EGoogle\u003C\u002Fa\u003E &nbsp;&bull;&nbsp; \u003Ca href=\"{outlookLink:pleaseSelect}\"\u003EOutlook\u003C\u002Fa\u003E&nbsp;&nbsp;\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003C\u002Ftbody\u003E\r\n\u003C\u002Ftable\u003E\r\n\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr\u003E\r\n\u003Ctd height=\"18\"\u003E&nbsp;\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr\u003E\r\n\u003Ctd\u003E\r\n\u003Ctable class=\"jmTable\" style=\"min-width: 480px; max-width: 720px; width: 100%; background-color: #fff; text-align: center;\" width=\"100%\" cellspacing=\"0\" cellpadding=\"0\"\u003E\r\n\u003Ctbody\u003E\r\n\u003Ctr\u003E\r\n\u003Ctd style=\"width: 100%; max-width: 100%; min-width: 100%;\"\u003E\u003Ca style=\"min-width: 64px; background-color: #ff6100; color: #fff; border-radius: 4px; font-size: 20px; font-weight: bold; line-height: 23px; text-align: center; padding: 16px 26px; display: inline-block; text-decoration: none; margin-top: 8px;\" href=\"{edit_link_v2}\"\u003E&nbsp;Reschedule or Cancel Appointment&nbsp;\u003C\u002Fa\u003E\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003C\u002Ftbody\u003E\r\n\u003C\u002Ftable\u003E\r\n\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003C\u002Ftbody\u003E\r\n\u003C\u002Ftable\u003E\r\n\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003C\u002Ftbody\u003E\r\n\u003C\u002Ftable\u003E\r\n\u003C\u002Ftd\u003E\r\n\u003Ctd style=\"min-width: 40px;\" width=\"40\"\u003E&nbsp;\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr style=\"min-height: 26px; background-color: #fff;\"\u003E\r\n\u003Ctd colspan=\"3\"\u003E&nbsp;\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003C\u002Ftbody\u003E\r\n\u003C\u002Ftable\u003E\r\n\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003C\u002Ftbody\u003E\r\n\u003C\u002Ftable\u003E\r\n\u003Cbr \u002F\u003E\r\n\u003Ctable class=\"jmTable-wrapper\" style=\"width: 100%;\" cellspacing=\"0\" cellpadding=\"0\"\u003E\r\n\u003Ctbody\u003E\r\n\u003Ctr style=\"display: none;\"\u003E\r\n\u003Ctd style=\"min-height: 64px;\" height=\"64\"\u003E&nbsp;\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr\u003E\r\n\u003Ctd align=\"center\"\u003E\r\n\u003Ctable class=\"jmTable\" style=\"min-width: 480px; max-width: 720px; width: 100%; background-color: #fff;\" width=\"100%\" cellspacing=\"0\" cellpadding=\"0\"\u003E\r\n\u003Ctbody\u003E\r\n\u003Ctr\u003E\r\n\u003Ctd style=\"width: 100%; max-width: 100%; min-width: 100%;\"\u003E\r\n\u003Ctable width=\"100%\" cellspacing=\"0\" cellpadding=\"0\"\u003E\r\n\u003Ctbody\u003E\r\n\u003Ctr style=\"min-height: 24px;\"\u003E\r\n\u003Ctd colspan=\"3\"\u003E&nbsp;\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr\u003E\r\n\u003Ctd style=\"min-width: 40px;\" width=\"40\"\u003E&nbsp;\u003C\u002Ftd\u003E\r\n\u003Ctd\u003E\u003Cspan id=\"jmTitle-container\" style=\"font-size: 18px; font-weight: bold; color: #0a1551;\"\u003E{form_title}\u003C\u002Fspan\u003E\u003C\u002Ftd\u003E\r\n\u003Ctd style=\"min-width: 40px;\" width=\"40\"\u003E&nbsp;\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr style=\"min-height: 16px;\"\u003E\r\n\u003Ctd style=\"min-width: 40px;\" width=\"40\"\u003E&nbsp;\u003C\u002Ftd\u003E\r\n\u003Ctd style=\"border-bottom: 1px solid #ECEDF2;\"\u003E&nbsp;\u003C\u002Ftd\u003E\r\n\u003Ctd style=\"min-width: 40px;\" width=\"40\"\u003E&nbsp;\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr\u003E\r\n\u003Ctd colspan=\"3\"\u003E\r\n\u003Ctable id=\"jmSubmission-container\" class=\"jmSubmissionTable\" style=\"width: 100%;\" cellspacing=\"0\" cellpadding=\"24\"\u003E\r\n\u003Ctbody id=\"emailFieldsTableBody\"\u003E\r\n\u003Ctr\u003E\r\n\u003Ctd\u003E\r\n\u003Ctable id=\"jmSubmission-container\" class=\"emailFieldsInnerTable\" width=\"100%\" cellspacing=\"0\" cellpadding=\"12\"\u003E\r\n\u003Ctbody id=\"emailFieldsTableInnerBody\"\u003E\r\n\u003Ctr id=\"row_3\" class=\"questionRow\"\u003E\r\n\u003Ctd id=\"question_3\" class=\"questionColumn\" style=\"color: #6f76a7; font-size: 14px;\" bgcolor=\"transparent\" width=\"40%\"\u003EPatient Name\u003C\u002Ftd\u003E\r\n\u003Ctd id=\"value_3\" class=\"valueColumn\" style=\"color: #0a1551; font-size: 14px;\" bgcolor=\"transparent\" width=\"60%\"\u003E{patientName}\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr id=\"row_4\" class=\"questionRow\"\u003E\r\n\u003Ctd id=\"question_4\" class=\"questionColumn\" style=\"color: #6f76a7; font-size: 14px;\" bgcolor=\"transparent\" width=\"40%\"\u003EPhone Number\u003C\u002Ftd\u003E\r\n\u003Ctd id=\"value_4\" class=\"valueColumn\" style=\"color: #0a1551; font-size: 14px;\" bgcolor=\"transparent\" width=\"60%\"\u003E{patientPhone}\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr id=\"row_5\" class=\"questionRow\"\u003E\r\n\u003Ctd id=\"question_5\" class=\"questionColumn\" style=\"color: #6f76a7; font-size: 14px;\" bgcolor=\"transparent\" width=\"40%\"\u003EEmail\u003C\u002Ftd\u003E\r\n\u003Ctd id=\"value_5\" class=\"valueColumn\" style=\"color: #0a1551; font-size: 14px;\" bgcolor=\"transparent\" width=\"60%\"\u003E{patientEmail}\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr id=\"row_6\" class=\"questionRow\"\u003E\r\n\u003Ctd id=\"question_6\" class=\"questionColumn\" style=\"color: #6f76a7; font-size: 14px;\" bgcolor=\"transparent\" width=\"40%\"\u003ETypes of Consultation\u003C\u002Ftd\u003E\r\n\u003Ctd id=\"value_6\" class=\"valueColumn\" style=\"color: #0a1551; font-size: 14px;\" bgcolor=\"transparent\" width=\"60%\"\u003E{typesOf}\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr id=\"row_10\" class=\"questionRow\"\u003E\r\n\u003Ctd id=\"question_10\" class=\"questionColumn\" style=\"color: #6f76a7; font-size: 14px;\" bgcolor=\"transparent\" width=\"40%\"\u003EPlease Select an Appointment Date\u003C\u002Ftd\u003E\r\n\u003Ctd id=\"value_10\" class=\"valueColumn\" style=\"color: #0a1551; font-size: 14px;\" bgcolor=\"transparent\" width=\"60%\"\u003E{pleaseSelect}\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr id=\"row_7\" class=\"questionRow\"\u003E\r\n\u003Ctd id=\"question_7\" class=\"questionColumn\" style=\"color: #6f76a7; font-size: 14px;\" bgcolor=\"transparent\" width=\"40%\"\u003EMedical History\u003C\u002Ftd\u003E\r\n\u003Ctd id=\"value_7\" class=\"valueColumn\" style=\"color: #0a1551; font-size: 14px;\" bgcolor=\"transparent\" width=\"60%\"\u003E{medicalHistory}\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr id=\"row_8\" class=\"questionRow\"\u003E\r\n\u003Ctd id=\"question_8\" class=\"questionColumn\" style=\"color: #6f76a7; font-size: 14px;\" bgcolor=\"transparent\" width=\"40%\"\u003EDo you have a health insurance?\u003C\u002Ftd\u003E\r\n\u003Ctd id=\"value_8\" class=\"valueColumn\" style=\"color: #0a1551; font-size: 14px;\" bgcolor=\"transparent\" width=\"60%\"\u003E{doYou}\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003Ctr id=\"row_9\" class=\"questionRow\"\u003E\r\n\u003Ctd id=\"question_9\" class=\"questionColumn\" style=\"color: #6f76a7; font-size: 14px;\" bgcolor=\"transparent\" width=\"40%\"\u003EAdditional Notes\u003C\u002Ftd\u003E\r\n\u003Ctd id=\"value_9\" class=\"valueColumn\" style=\"color: #0a1551; font-size: 14px;\" bgcolor=\"transparent\" width=\"60%\"\u003E{additionalMedical}\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003C\u002Ftbody\u003E\r\n\u003C\u002Ftable\u003E\r\n\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003C\u002Ftbody\u003E\r\n\u003C\u002Ftable\u003E\r\n\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003C\u002Ftbody\u003E\r\n\u003C\u002Ftable\u003E\r\n\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003C\u002Ftbody\u003E\r\n\u003C\u002Ftable\u003E\r\n\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003C\u002Ftbody\u003E\r\n\u003C\u002Ftable\u003E\r\n\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003C\u002Ftbody\u003E\r\n\u003C\u002Ftable\u003E\r\n\u003C\u002Ftd\u003E\r\n\u003Ctd style=\"width: 32px; min-width: 32px;\" width=\"32\"\u003E&nbsp;\u003C\u002Ftd\u003E\r\n\u003C\u002Ftr\u003E\r\n\u003C\u002Ftbody\u003E\r\n\u003C\u002Ftable\u003E\r\n\u003C\u002Fbody\u003E\r\n\u003C\u002Fhtml\u003E","senderName":"BEAUTEZ PHARMACY","replyTo":[{"id":"73f6852b-c398-4c29-9ee2-772326ee77ee","value":"btzpharmacy@gmail.com","text":"btzpharmacy@gmail.com","isValid":"true","isQuestion":"false"}],"branding21Email":"1","attachment":"undefined","senderEmail":"noreply@jotform.com","hideEmptyFields":"false","sendOnEdit":"false","sendOnSubmit":"undefined","enablePDFPassword":"false","isPDFPasswordRequiredOnHIPAA":"true","sendDate":"undefined","usesNewPDF":"Yes","selectedPDFOptions":[""],"recipientLimit":"0","teamMembers":"undefined","cc":"undefined","bcc":"undefined"}}},"type":{"hidden":true,"value":"control_appointment"},"useReminderEmails":{"hidden":true,"value":"Yes"},"id":{"value":"10"},"qname":{"value":"q10_pleaseSelect"},"formProperties":{"title":{"text":"Title","value":"Telemedicine Appointment Application","toolbar":false,"tab":"general","type":"text"},"pagetitle":{"text":"Page Title","value":"Telemedicine Appointment Application","toolbar":false,"tab":"general","type":"text"},"themeDesigner":{"text":"Form 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Alignment","value":"Top","dropdown":[["Left","Left"],["Top","Top"],["Right","Right"]],"tab":"fieldStyle","type":"select"},"thankurl":{"text":"Thank You URL","value":"","hidden":true,"type":"url"},"thanktext":{"text":"Thank You Text","value":"\u003Cp style=\"text-align: center;\" data-mce-style=\"text-align: center;\"\u003E\u003Cimg src=\"https:\u002F\u002Fwww.jotform.com\u002Fuploads\u002Flesodecanalytics\u002Fform_files\u002FBold%20Blue%20and%20White%20Clean%20Modern%20Health%20Clinic%20Trifold%20Brochure.6696dbb9b69919.66691203.png\" alt=\"\" width=\"286\" height=\"202\" data-mce-src=\"https:\u002F\u002Fwww.jotform.com\u002Fuploads\u002Flesodecanalytics\u002Fform_files\u002FBold%20Blue%20and%20White%20Clean%20Modern%20Health%20Clinic%20Trifold%20Brochure.6696dbb9b69919.66691203.png\"\u003E\u003C\u002Fp\u003E\u003Cdiv style=\"text-align: center;\" data-mce-style=\"text-align: center;\"\u003E\u003Ch1 style=\"text-align: center;\" data-mce-style=\"text-align: center;\"\u003E\u003Cstrong\u003EThank You!\u003C\u002Fstrong\u003E\u003C\u002Fh1\u003E\u003Cp style=\"text-align: center;\" data-mce-style=\"text-align: center;\"\u003EYour submission has been received.\u003C\u002Fp\u003E\u003C\u002Fdiv\u003E\u003Cdiv class=\"nonEditableInvisable\" contenteditable=\"false\"\u003E\n      \u003Cdiv class=\"thankYouButtonWrapper notActive \" style=\"display: none\" contenteditable=\"false\"\u003E\n        \u003Cdiv class=\"thankYouFillAgain thankYouFillAgainWrapper tyWrapper notActive\" contenteditable=\"false\" style=\"display: none\"\u003E\n          \u003Cdiv class=\"thankyou-btn-wrapper\" contenteditable=\"false\"\u003E\n            \u003Ca class=\"ty-buttons thankYouFillAgain\" role=\"button\" aria-label=\"fill again button\" contenteditable=\"false\" style=\"color:false; background-color:false; border-color:false;text-decoration:none;\" href=\"\u002F250212560938555\"\u003E\n            Fill Again\n            \u003C\u002Fa\u003E\n          \u003C\u002Fdiv\u003E\n        \u003C\u002Fdiv\u003E\n        \u003Cdiv class=\"thankYouEditSubmission thankYouEditSubmissionWrapper tyWrapper notActive\" contenteditable=\"false\" style=\"display: none\"\u003E\n          \u003Cdiv class=\"thankyou-btn-wrapper\" role=\"button\" aria-label=\"Edit submission button\" contenteditable=\"false\"\u003E\n            \u003Ca href=\"{edit_link_v2}\" class=\"ty-buttons thankYouEditSubmission\" contenteditable=\"false\" style=\"text-decoration:none; border-color:false;\"\u003E\n            Edit Submission\n            \u003C\u002Fa\u003E\n          \u003C\u002Fdiv\u003E\n        \u003C\u002Fdiv\u003E\n        \u003Cdiv class=\"thankYouViewCompletedTask thankYouViewCompletedTaskWrapper tyWrapper notActive\" contenteditable=\"false\" style=\"display: none\"\u003E\n          \u003Cdiv class=\"thankyou-btn-wrapper\" role=\"button\" aria-label=\"View completed task\" contenteditable=\"false\"\u003E\n            \u003Ca href=\"{view_completed_task}\" class=\"ty-buttons thankYouViewCompletedTask\" contenteditable=\"false\" style=\"text-decoration:none; border-color:#0075E3; background-color: #0075E3; color: #fff; font-weight: 500\"\u003E\n            View your completed task\n            \u003C\u002Fa\u003E\n          \u003C\u002Fdiv\u003E\n        \u003C\u002Fdiv\u003E\n      \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E\u003Cdiv class=\"nonEditableInvisable isFillAnotherForm notActive\" style=\"display: none\" contenteditable=\"false\"\u003E\n    \u003Cdiv class=\"thankYouFillAnotherForm thankYouFillAnotherFormWrapper tyWrapper notActive\" contenteditable=\"false\" style=\"border-top:1px solid false; display: none\"\u003E\n      \u003Cul class=\"thankYouFillAnotherFormList\" contenteditable=\"false\"\u003E\u003C\u002Ful\u003E\n    \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E\u003Cdiv class=\"nonEditableInvisable isPDF notActive\" style=\"display: none\" contenteditable=\"false\"\u003E\n    \u003Cdiv class=\"thankYouDownloadPDF thankYouDownloadPDFWrapper tyWrapper notActive\" contenteditable=\"false\" style=\"border-top:1px solid false; display: none\"\u003E\n      \u003Cul class=\"thankYouPDFList\" contenteditable=\"false\"\u003E\u003Cli class=\"downloadPDFItem downloadPDFItem-10250224836746056 notActive\" contenteditable=\"false\" key=\"10250224836746056\" title=\"Telemedicine Appointment Document\" style=\"display: none;\"\u003E\u003Cdiv class=\"pdf-image-wrapper\" contenteditable=\"false\"\u003E\n      \u003Cspan class=\"pdf-SVG\" role=\"img\" aria-label=\"pdf icon\" contenteditable=\"false\"\u003E&nbsp;\u003C\u002Fspan\u003E\n    \u003C\u002Fdiv\u003E\n    \u003Cdiv class=\"pdf-name-wrapper\" contenteditable=\"false\"\u003E\n      \u003Cspan class=\"pdf-name\" contenteditable=\"false\"\u003E{patientName} {beautezPharmacy}.pdf\u003C\u002Fspan\u003E\n    \u003C\u002Fdiv\u003E\n    \u003Cdiv class=\"thankyou-btn-wrapper\" contenteditable=\"false\"\u003E\n      \u003Ca href=\"{new-pdf-link|10250224836746056}\" class=\"ty-buttons thankYouDownloadPDF\" contenteditable=\"false\" style=\"text-decoration:none; border-color:false;\" role=\"button\" aria-label=\"download pdf button\"\u003E\n      Download PDF\n      \u003C\u002Fa\u003E\n    \u003C\u002Fdiv\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\n    \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E\u003Cdiv class=\"nonEditableInvisable isVisitURL notActive\" style=\"display: none\" contenteditable=\"false\"\u003E\n      \u003Cdiv class=\"thankYouVisitURL thankYouVisitURLFormWrapper tyWrapper notActive\" contenteditable=\"false\" style=\"border-top:1px solid ; display: none\"\u003E\n        \u003Cul class=\"thankYouVisitURLFormList\" contenteditable=\"false\"\u003E\n          \u003Cli class=\"visitURLItem\" key=\"undefined\" title=\"undefined\" style=\"display: none;\" contenteditable=\"false\"\u003E\n            \u003Ca class=\"thankYouVisitURL\" href=\"\" rel=\"noopener noreferrer\" target=\"_blank\" contenteditable=\"false\"\u003E\n              \u003Cspan class=\"visitURL-image-wrapper\" contenteditable=\"false\"\u003E\n                \n              \u003C\u002Fspan\u003E\n\n              \u003Cspan class=\"visitURL-context\" contenteditable=\"false\"\u003E\n                \u003Cspan class=\"visitURL-name\"\u003Eundefined\u003C\u002Fspan\u003E\n                \u003Cspan class=\"visitURL-description\"\u003Eundefined\u003C\u002Fspan\u003E\n              \u003C\u002Fspan\u003E\n            \u003C\u002Fa\u003E\n          \u003C\u002Fli\u003E\n        \u003C\u002Ful\u003E\n      \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E","textarea":true,"hidden":true,"type":"textarea"},"highlightLine":"Enabled","activeRedirect":{"text":"Active Redirect","value":"thanktext","dropdown":[["default","Default"],["thankurl","Thank You URL"],["thanktext","Thank You Text"]],"hidden":true,"type":"select"},"sendpostdata":{"text":"Send Post Data","value":"No","dropdown":[["No","No"],["Yes","Yes"]],"toolbar":false,"tab":"advanced","type":"select"},"unique":{"text":"Unique Submission","value":"None","dropdown":[["None","No check"],["Loose","Check cookies only"],["Strict","Check cookies and IP address"]],"toolbar":false,"tab":"formLimits","type":"select"},"uniqueField":{"text":"Unique Field","value":"\u003CField Id\u003E","dropdown":[["\u003CField Id\u003E","No Check"]],"toolbar":false,"tab":"formLimits","type":"select"},"status":{"text":"Status","value":"Enabled","dropdown":[["Enabled","Enabled"],["Disabled","Disabled"]],"toolbar":false,"tab":"general","type":"select"},"responsive":{"text":"Responsive Form","value":"No","dropdown":[["No","No"],["Yes","Yes"]],"toolbar":false,"tab":"general","type":"select"},"injectCSS":{"text":"Inject Custom CSS","value":"\u002F*PREFERENCES STYLE*\u002F\n    .form-all {\n      font-family: Trebuchet MS, sans-serif;\n    }\n  \n    .form-label.form-label-auto {\n      \n    display: block;\n    float: none;\n    text-align: left;\n    width: 100%;\n  \n    }\n  \n    .form-line {\n      margin-top: 12px;\n      margin-bottom: 12px;\n    }\n  \n    .form-all {\n      max-width: 752px;\n      width: 100%;\n    }\n  \n    .form-label.form-label-left,\n    .form-label.form-label-right,\n    .form-label.form-label-left.form-label-auto,\n    .form-label.form-label-right.form-label-auto {\n      width: 230px;\n    }\n  \n    .form-all {\n      font-size: 16px\n    }\n  \n    .supernova .form-all, .form-all {\n      background-color: #fff;\n    }\n  \n    .form-all {\n      color: #2C3345;\n    }\n    .form-header-group .form-header {\n      color: #2C3345;\n    }\n    .form-header-group .form-subHeader {\n      color: #2C3345;\n    }\n    .form-label-top,\n    .form-label-left,\n    .form-label-right,\n    .form-html,\n    .form-checkbox-item label,\n    .form-radio-item label,\n    span.FITB .qb-checkbox-label,\n    span.FITB .qb-radiobox-label,\n    span.FITB .form-radio label,\n    span.FITB .form-checkbox label,\n    [data-blotid][data-type=checkbox] [data-labelid],\n    [data-blotid][data-type=radiobox] [data-labelid],\n    span.FITB-inptCont[data-type=checkbox] label,\n    span.FITB-inptCont[data-type=radiobox] label {\n      color: #2C3345;\n    }\n    .form-sub-label {\n      color: #464d5f;\n    }\n  \n  .supernova {\n    background-color: undefined;\n  }\n  .supernova body {\n    background: transparent;\n  }\n  \n    .form-textbox,\n    .form-textarea,\n    .form-dropdown,\n    .form-radio-other-input,\n    .form-checkbox-other-input,\n    .form-captcha input,\n    .form-spinner input {\n      background-color: undefined;\n    }\n  \n    \n    .supernova {\n      background-repeat: no-repeat;\n      background-size:cover;\n      background-attachment: fixed;\n      background-position: center top;\n    }\n\n    .supernova, #stage {\n      background-image: url(\"https:\u002F\u002Fwww.jotform.com\u002Fuploads\u002Fceren\u002Fform_files\u002Fjobapp.539.jpg\");\n    }\n      .form-all {\n        background-image: none;\n      }\n    \u002F*PREFERENCES STYLE*\u002F\u002F*__INSPECT_SEPERATOR__*\u002F.form-all {\n    box-shadow : none;\n    border-radius: 8px;\n}\n.header-logo img{\n    border-radius: 0 8px 0 0;\n}\n\n.header-text{\n  padding: 20px\n}\n\n.form-subHeader {\n  opacity:0.5;\n}\n\n\n","textarea":true,"toolbar":false,"tab":"formStyle","type":"textarea"},"hideMailEmptyFields":{"text":"Hide Empty Fields on Emails","value":"enable","dropdown":[["enable","Enabled"],["disable","Disabled"]],"tab":"advanced","type":"select"},"mobileGoButton":{"text":"GO button submits form","value":"enable","dropdown":[["enable","Enabled"],["disable","Disabled"]],"tab":"advanced","type":"select"},"clearFieldOnHide":{"text":"Clear Hidden Field Values","value":"disable","dropdown":[["enable","Clear when hidden"],["disable","Clear when submitted"],["dontClear","Don't clear"]],"tab":"advanced","type":"select"},"onSubmissionError":{"text":"On Submission Error","value":"jumpToFirstError","dropdown":[["jumpToSubmit","Jump To Submit Button"],["jumpToFirstError","Jump to First Error"],["doNothing","Do Nothing"]],"tab":"advanced","type":"select"},"showProgressBar":{"text":"Show Progress Bar on Form","value":"disable","dropdown":[["enable","Enabled"],["disable","Disabled"]],"tab":"advanced","type":"select"},"autoFill":{"text":"Save and Continue Later","value":[{"menu":"disable","timeout":4,"ttl":86400,"bindChange":"on"}],"dropdown":[["enable","Enabled"],["disable","Disabled"]],"tab":"advanced","type":"select"},"language":{"text":"Languages","value":[{"detectUserLanguage":"1","firstPageOnly":"0","options":"English (US)","originalLanguage":"en","primaryLanguage":"en","saveUserLanguage":"1","showStatus":"flag-with-nation","theme":"light-theme","version":"2"}],"tab":"advanced","hidden":false,"toolbar":true},"formStrings":{"text":"Form Warnings","value":[{"startButtonText":"START"}],"tab":"advanced"},"formCover":{"text":"Form Cover","value":false,"tab":"advanced"},"isEncrypted":{"text":"Encrypt Form Data","value":"No","dropdown":[["No","No"],["Yes","Yes"]],"toolbar":false,"tab":"advanced","type":"select"},"welcomePage":{"text":"Welcome Page Properties","value":[{"buttonText":"START","isActive":"1","logo":"https:\u002F\u002Fwww.jotform.com\u002Fuploads\u002Flesodecanalytics\u002Fform_files\u002FBlue%20and%20White%20Modern%20Medical%20Healthcare%20Presentation%20%281%29.6790c7d4b866b9.28462767.png","showQuestionCount":"Yes","subTitle":"Please fill out and book your appointment.","title":"Welcome To Telehealth Platform"}],"hidden":true,"toolbar":false,"tab":"advanced","type":"select"},"thankYouPage":{"text":"ThankYou Page Properties","value":[{"imageSrc":"https:\u002F\u002Fcdn.jotfor.ms\u002Fimg\u002Fcheck-icon.png","redirectLink":"https:\u002F\u002Fwww.jotform.com","subTitle":"Your submission has been received!","title":"Thank You!","type":"text"}],"hidden":true,"toolbar":false,"tab":"advanced","type":"select"},"limitSubmission":{"text":"Submission Limit","value":"No Limit","toolbar":false,"tab":"formLimits","type":"text"},"expireDate":{"text":"Expiration Date","value":"No Limit","toolbar":false,"tab":"formLimits","type":"datetime"},"messageOfLimitedForm":{"text":"Warning Message","value":"This form is currently unavailable!","toolbar":false,"tab":"formLimits","type":"text"},"emails":{"text":"Emails","value":[{"aiEditedEmail":"0","aiGeneratedEmail":"0","body":"\u003C!DOCTYPE html PUBLIC \"-\u002F\u002FW3C\u002F\u002FDTD HTML 4.0 Transitional\u002F\u002FEN\" \"http:\u002F\u002Fwww.w3.org\u002FTR\u002FREC-html40\u002Floose.dtd\"\u003E\n\u003Chtml\u003E\u003Chead\u003E\u003Cmeta name=\"viewport\" content=\"width=device-width\"\u003E\u003Cmeta http-equiv=\"X-UA-Compatible\" content=\"IE=edge\"\u003E\u003Cmeta name=\"x-apple-disable-message-reformatting\"\u003E\u003Cstyle\u003E\n                    .forward-text-show {\n                        display: block !important;\n                        color: #0a1551 !important;\n                        text-align: center!important; \n                        font-size: 13px!important;\n                    }\n                    .line-show {\n                        display: table-row !important;\n                    }\n                    .forward-link-show {\n                        display : inline-block !important;\n                        color: #4573E3 !important;\n                        text-decoration: underline !important;\n                        cursor: none !important;\n                    }\n                    table {\n                        border-spacing: 0 !important;\n                        border-collapse: collapse !important;\n                        margin: 0 auto !important;\n                    }\n                    table, td {\n                        border-spacing: 0 !important;\n                        border-collapse:collapse !important;\n                    }\n                    @media screen and (max-device-width: 700px), screen and (max-width: 700px) {\n                        .email-container {\n                            width: 100% !important;\n                            margin: auto !important;\n                        }\n                        .mobile-padding-fix {\n                            padding-left: 15px !important;\n                            padding-right: 15px !important;\n                        }\n                    }\n                    @media screen and (max-device-width: 480px), screen and (max-width: 480px) {\n                        td.questionColumn, td.valueColumn, td.footerCol1, td.footerCol2 {\n                            display: block !important;\n                            width: 100% !important;\n                        }\n                        td.questionColumn {\n                            padding: 0 !important;\n                        }\n                        td.valueColumn {\n                            padding: 4px 0 16px !important;\n                        }\n                        td.footerCol1, td.footerCol2 {\n                            text-align: center !important;\n                        }\n                        td.footerCol1 {\n                            padding-bottom: 16px\n                        }\n                        .mobile-column tr{ \n                            display:table-row;\n                            text-align: center!important;\n                            float: none!important;\n                            margin: 0 auto!important;\n                            max-width:100%!important;\n                        }\n                        .mobile-column td{ \n                            display:block;\n                            text-align: center!important;\n                            float: none!important;\n                            margin: 0 auto!important;\n                            max-width:100%!important;\n                        }\n                        .mobile-column .column-1{ \n                           padding:10px 0 0 0!important;\n                        }\n                        .mobile-column .column-2{ \n                           padding:0 0 10px 0!important\n                        }\n                        .mobile-column td .text-1{ \n                            padding-top:10px!important;\n                            text-align: center!important;\n                        }\n                        .mobile-column td .text-2{ \n                            text-align: center!important;\n                        }\n                        .mobile-column td .counter{ \n                            width:55px!important;\n                            height:55px!important;\n                            min-height:55px!important;\n                            max-height:55px!important;\n                            text-align: center!important;\n                            margin:0 auto!important;\n                            font-size: 14px!important;\n                            line-height: 55px!important;\n                        }\n                        .mobile-column .upgrade-now-btn{ \n                            margin: 0 auto!important;\n                            display: inline-block!important;\n                            text-align: center!important;\n                            float: none!important;\n                            min-width: initial!important;\n                        }\n                        .mobile-column .column-1{ \n                           border:0!important;\n                        }\n                    }\n                \u003C\u002Fstyle\u003E\u003Cmeta charset=\"utf-8\"\u003E\u003C\u002Fhead\u003E\u003Cbody\u003E\n\u003Cp\u003E\u003Cimg src=\"https:\u002F\u002Fwww.jotform.com\u002Fuploads\u002Flesodecanalytics\u002Fform_files\u002FBlue%20and%20White%20Modern%20Medical%20Healthcare%20Presentation%20%281%29.6790c7d4b866b9.28462767.png\" alt=\"\" width=\"610\" height=\"343\"\u003E\u003C\u002Fp\u003E\n\u003Cp style=\"color: #000000; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 14px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;\"\u003EDear Healthcare Professional&nbsp;\u003C\u002Fp\u003E\n\u003Cp style=\"color: #000000; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 14px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;\"\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp style=\"color: #000000; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 14px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;\"\u003EPlease see below appointment bookings for a patient and secure your availability.\u003C\u002Fp\u003E\n\u003Cp style=\"color: #000000; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 14px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;\"\u003EYour coorporation will be highly appreciated.\u003C\u002Fp\u003E\n\u003Cp style=\"color: #000000; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 14px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;\"\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp style=\"color: #000000; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 14px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;\"\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp style=\"color: #000000; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 14px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;\"\u003EWarm Regards&nbsp;\u003C\u002Fp\u003E\n\u003Cp style=\"color: #000000; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 14px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;\"\u003EBeautez Group pty ltd&nbsp;\u003C\u002Fp\u003E\n\u003Cp style=\"color: #000000; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 14px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;\"\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Ctable style=\"height: 56px; width: 606px; float: left;\"\u003E\u003Ctbody\u003E\u003Ctr\u003E\u003Ctd style=\"width: 191.125px;\"\u003EConsulting Doctor&nbsp;\u003C\u002Ftd\u003E\n\u003Ctd style=\"width: 406.875px;\"\u003E&nbsp;{consultingDoctor}\u003C\u002Ftd\u003E\n\u003C\u002Ftr\u003E\u003Ctr\u003E\u003Ctd style=\"width: 191.125px;\"\u003EEmails&nbsp;\u003C\u002Ftd\u003E\n\u003Ctd style=\"width: 406.875px;\"\u003E&nbsp;{doctorEmail}\u003C\u002Ftd\u003E\n\u003C\u002Ftr\u003E\u003Ctr\u003E\u003Ctd style=\"width: 191.125px;\"\u003ETel No\u003C\u002Ftd\u003E\n\u003Ctd style=\"width: 406.875px;\"\u003E&nbsp;{phoneNumber17}\u003C\u002Ftd\u003E\n\u003C\u002Ftr\u003E\u003Ctr\u003E\u003Ctd style=\"width: 191.125px;\"\u003E\n\u003Cp\u003E{pleaseSelect}\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003C\u002Ftd\u003E\n\u003Ctd style=\"width: 406.875px;\"\u003E&nbsp;\u003C\u002Ftd\u003E\n\u003C\u002Ftr\u003E\u003Ctr\u003E\u003Ctd style=\"width: 191.125px;\"\u003EPATIENT INFORMATION\u003C\u002Ftd\u003E\n\u003Ctd style=\"width: 406.875px;\"\u003E&nbsp;\u003C\u002Ftd\u003E\n\u003C\u002Ftr\u003E\u003Ctr\u003E\u003Ctd style=\"width: 191.125px;\"\u003E&nbsp;\u003C\u002Ftd\u003E\n\u003Ctd style=\"width: 406.875px;\"\u003E&nbsp;\u003C\u002Ftd\u003E\n\u003C\u002Ftr\u003E\u003Ctr\u003E\u003Ctd style=\"width: 191.125px;\"\u003EPatient Names\u003C\u002Ftd\u003E\n\u003Ctd style=\"width: 406.875px;\"\u003E{patientName}\u003C\u002Ftd\u003E\n\u003C\u002Ftr\u003E\u003Ctr\u003E\u003Ctd style=\"width: 191.125px;\"\u003EType of consultation&nbsp;\u003C\u002Ftd\u003E\n\u003Ctd style=\"width: 406.875px;\"\u003E{typesOf}\u003C\u002Ftd\u003E\n\u003C\u002Ftr\u003E\u003Ctr\u003E\u003Ctd style=\"width: 191.125px;\"\u003E&nbsp;\u003C\u002Ftd\u003E\n\u003Ctd style=\"width: 406.875px;\"\u003E&nbsp;\u003C\u002Ftd\u003E\n\u003C\u002Ftr\u003E\u003Ctr\u003E\u003Ctd style=\"width: 191.125px;\"\u003E&nbsp;\u003C\u002Ftd\u003E\n\u003Ctd style=\"width: 406.875px;\"\u003E&nbsp;\u003C\u002Ftd\u003E\n\u003C\u002Ftr\u003E\u003Ctr\u003E\u003Ctd style=\"width: 191.125px;\"\u003E\n\u003Cp\u003E\u003Cspan style=\"color: #2c3345; font-family: Inter, Lucida Grande, Lucida Sans Unicode, Lucida Sans, Verdana, sans-serif; font-size: 16px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 500; letter-spacing: normal; orphans: 2; text-align: left; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: pre-wrap; background-color: #ffffff; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;\"\u003EMedical History\u003C\u002Fspan\u003E\u003C\u002Fp\u003E\n\u003Cp\u003E{medicalHistory}\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003C\u002Ftd\u003E\n\u003Ctd style=\"width: 406.875px;\"\u003E&nbsp;\u003C\u002Ftd\u003E\n\u003C\u002Ftr\u003E\u003Ctr\u003E\u003Ctd style=\"width: 191.125px;\"\u003E\n\u003Cp\u003EAdditional Med History&nbsp;\u003C\u002Fp\u003E\n\u003Cp\u003E{additionalMedical}\u003C\u002Fp\u003E\n\u003C\u002Ftd\u003E\n\u003Ctd style=\"width: 406.875px;\"\u003E&nbsp;\u003C\u002Ftd\u003E\n\u003C\u002Ftr\u003E\u003Ctr\u003E\u003Ctd style=\"width: 191.125px;\"\u003EMedical Aid&nbsp;\u003C\u002Ftd\u003E\n\u003Ctd style=\"width: 406.875px;\"\u003E{doYou}\u003C\u002Ftd\u003E\n\u003C\u002Ftr\u003E\u003Ctr\u003E\u003Ctd style=\"width: 191.125px;\"\u003E&nbsp;\u003C\u002Ftd\u003E\n\u003Ctd style=\"width: 406.875px;\"\u003E&nbsp;\u003C\u002Ftd\u003E\n\u003C\u002Ftr\u003E\u003C\u002Ftbody\u003E\u003C\u002Ftable\u003E\u003Cp\u003E\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003C\u002Fbody\u003E\u003C\u002Fhtml\u003E\n","bodyRevised":"1","dirty":"1","dirtyEmail":"1","disabled":"0","from":"smtp:77250103029403036|{typesOf}","hideEmptyFields":"1","html":"1","lastQuestionID":"44","name":"Notification 1","newDisableFlow":"0","pdfattachment":"1","pdfId":"10250224836746056","replyTo":"{patientEmail}","sendOnEdit":"1","sendOnSubmit":"1","subject":"Re: {form_title} - {patientName}","to":"btzpharmacy@gmail.com,khotson@beautezpharma.com","type":"notification","uniqueID":"250212324644042","updateEmail":"1","uploadAttachment":"1"},{"aiEditedEmail":"0","aiGeneratedEmail":"0","body":"\u003C!DOCTYPE html PUBLIC \"-\u002F\u002FW3C\u002F\u002FDTD HTML 4.0 Transitional\u002F\u002FEN\" \"http:\u002F\u002Fwww.w3.org\u002FTR\u002FREC-html40\u002Floose.dtd\"\u003E\n\u003Chtml\u003E\u003Chead\u003E\u003Cmeta name=\"viewport\" content=\"width=device-width\"\u003E\u003Cmeta http-equiv=\"X-UA-Compatible\" content=\"IE=edge\"\u003E\u003Cmeta name=\"x-apple-disable-message-reformatting\"\u003E\u003Cstyle\u003E\n                    .forward-text-show {\n                        display: block !important;\n                        color: #0a1551 !important;\n                        text-align: center!important; \n                        font-size: 13px!important;\n                    }\n                    .line-show {\n                        display: table-row !important;\n                    }\n                    .forward-link-show {\n                        display : inline-block !important;\n                        color: #4573E3 !important;\n                        text-decoration: underline !important;\n                        cursor: none !important;\n                    }\n                    table {\n                        border-spacing: 0 !important;\n                        border-collapse: collapse !important;\n                        margin: 0 auto !important;\n                    }\n                    table, td {\n                        border-spacing: 0 !important;\n                        border-collapse:collapse !important;\n                    }\n                    @media screen and (max-device-width: 700px), screen and (max-width: 700px) {\n                        .email-container {\n                            width: 100% !important;\n                            margin: auto !important;\n                        }\n                        .mobile-padding-fix {\n                            padding-left: 15px !important;\n                            padding-right: 15px !important;\n                        }\n                    }\n                    @media screen and (max-device-width: 480px), screen and (max-width: 480px) {\n                        td.questionColumn, td.valueColumn, td.footerCol1, td.footerCol2 {\n                            display: block !important;\n                            width: 100% !important;\n                        }\n                        td.questionColumn {\n                            padding: 0 !important;\n                        }\n                        td.valueColumn {\n                            padding: 4px 0 16px !important;\n                        }\n                        td.footerCol1, td.footerCol2 {\n                            text-align: center !important;\n                        }\n                        td.footerCol1 {\n                            padding-bottom: 16px\n                        }\n                        .mobile-column tr{ \n                            display:table-row;\n                            text-align: center!important;\n                            float: none!important;\n                            margin: 0 auto!important;\n                            max-width:100%!important;\n                        }\n                        .mobile-column td{ \n                            display:block;\n                            text-align: center!important;\n                            float: none!important;\n                            margin: 0 auto!important;\n                            max-width:100%!important;\n                        }\n                        .mobile-column .column-1{ \n                           padding:10px 0 0 0!important;\n                        }\n                        .mobile-column .column-2{ \n                           padding:0 0 10px 0!important\n                        }\n                        .mobile-column td .text-1{ \n                            padding-top:10px!important;\n                            text-align: center!important;\n                        }\n                        .mobile-column td .text-2{ \n                            text-align: center!important;\n                        }\n                        .mobile-column td .counter{ \n                            width:55px!important;\n                            height:55px!important;\n                            min-height:55px!important;\n                            max-height:55px!important;\n                            text-align: center!important;\n                            margin:0 auto!important;\n                            font-size: 14px!important;\n                            line-height: 55px!important;\n                        }\n                        .mobile-column .upgrade-now-btn{ \n                            margin: 0 auto!important;\n                            display: inline-block!important;\n                            text-align: center!important;\n                            float: none!important;\n                            min-width: initial!important;\n                        }\n                        .mobile-column .column-1{ \n                           border:0!important;\n                        }\n                    }\n                \u003C\u002Fstyle\u003E\u003Cmeta charset=\"utf-8\"\u003E\u003C\u002Fhead\u003E\u003Cbody\u003E\n\u003Cp\u003E\u003Cimg style=\"float: left;\" src=\"https:\u002F\u002Fwww.jotform.com\u002Fuploads\u002Flesodecanalytics\u002Fform_files\u002FBlue%20and%20White%20Modern%20Medical%20Healthcare%20Presentation%20%281%29.6790c7d4b866b9.28462767.png\" alt=\"\" width=\"565\" height=\"344\"\u003E\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Ctable style=\"height: 120px; float: left;\" width=\"564\"\u003E\u003Ctbody\u003E\u003Ctr\u003E\u003Ctd style=\"width: 278.5px;\"\u003E\n\u003Cp\u003EDear {patientName},\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp\u003EThank you for choosing Beautez Pharmacy as your trusted healthcare partner. We are pleased to confirm that your appointment has been approved.\u003C\u002Fp\u003E\n\u003Cp\u003EWe look forward to welcoming you on the scheduled date and providing you with the exceptional care you deserve.\u003C\u002Fp\u003E\n\u003Cp\u003EIf you have any questions or need further assistance before your visit, please don&rsquo;t hesitate to reach out.\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp\u003EBest regards,\u003C\u002Fp\u003E\n\u003Cp\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp style=\"color: #000000; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 14px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;\"\u003EBeautez Group pty ltd&nbsp;\u003C\u002Fp\u003E\n\u003C\u002Ftd\u003E\n\u003C\u002Ftr\u003E\u003Ctr\u003E\u003Ctd style=\"width: 278.5px;\"\u003E&nbsp;\u003C\u002Ftd\u003E\n\u003C\u002Ftr\u003E\u003Ctr\u003E\u003Ctd style=\"width: 278.5px;\"\u003E&nbsp;\u003C\u002Ftd\u003E\n\u003C\u002Ftr\u003E\u003C\u002Ftbody\u003E\u003C\u002Ftable\u003E\u003C\u002Fbody\u003E\u003C\u002Fhtml\u003E\n","bodyRevised":"1","dirty":"1","dirtyEmail":"1","disabled":"0","from":"smtp:77250103029403036|BEAUTEZ PHARMACY","hideEmptyFields":"1","html":"1","lastQuestionID":"44","name":"Autoresponder 1","newDisableFlow":"0","pdfattachment":"1","pdfId":"10250224836746056","replyTo":"btzpharmacy@gmail.com","sendOnEdit":"1","sendOnSubmit":"1","subject":"We have received your response for {form_title}","to":"{patientEmail}","type":"autorespond","uniqueID":"250212324628044","updateEmail":"1"},{"aiEditedEmail":"0","aiGeneratedEmail":"0","body":"\u003C!DOCTYPE html PUBLIC \"-\u002F\u002FW3C\u002F\u002FDTD HTML 4.0 Transitional\u002F\u002FEN\" \"http:\u002F\u002Fwww.w3.org\u002FTR\u002FREC-html40\u002Floose.dtd\"\u003E\n\u003Chtml\u003E\u003Chead\u003E\u003Cmeta name=\"viewport\" content=\"width=device-width\"\u003E\u003Cmeta http-equiv=\"X-UA-Compatible\" content=\"IE=edge\"\u003E\u003Cmeta name=\"x-apple-disable-message-reformatting\"\u003E\u003Cstyle\u003E\n                    .forward-text-show {\n                        display: block !important;\n                        color: #0a1551 !important;\n                        text-align: center!important; \n                        font-size: 13px!important;\n                    }\n                    .line-show {\n                        display: table-row !important;\n                    }\n                    .forward-link-show {\n                        display : inline-block !important;\n                        color: #4573E3 !important;\n                        text-decoration: underline !important;\n                        cursor: none !important;\n                    }\n                    table {\n                        border-spacing: 0 !important;\n                        border-collapse: collapse !important;\n                        margin: 0 auto !important;\n                    }\n                    table, td {\n                        border-spacing: 0 !important;\n                        border-collapse:collapse !important;\n                    }\n                    @media screen and (max-device-width: 700px), screen and (max-width: 700px) {\n                        .email-container {\n                            width: 100% !important;\n                            margin: auto !important;\n                        }\n                        .mobile-padding-fix {\n                            padding-left: 15px !important;\n                            padding-right: 15px !important;\n                        }\n                    }\n                    @media screen and (max-device-width: 480px), screen and (max-width: 480px) {\n                        td.questionColumn, td.valueColumn, td.footerCol1, td.footerCol2 {\n                            display: block !important;\n                            width: 100% !important;\n                        }\n                        td.questionColumn {\n                            padding: 0 !important;\n                        }\n                        td.valueColumn {\n                            padding: 4px 0 16px !important;\n                        }\n                        td.footerCol1, td.footerCol2 {\n                            text-align: center !important;\n                        }\n                        td.footerCol1 {\n                            padding-bottom: 16px\n                        }\n                        .mobile-column tr{ \n                            display:table-row;\n                            text-align: center!important;\n                            float: none!important;\n                            margin: 0 auto!important;\n                            max-width:100%!important;\n                        }\n                        .mobile-column td{ \n                            display:block;\n                            text-align: center!important;\n                            float: none!important;\n                            margin: 0 auto!important;\n                            max-width:100%!important;\n                        }\n                        .mobile-column .column-1{ \n                           padding:10px 0 0 0!important;\n                        }\n                        .mobile-column .column-2{ \n                           padding:0 0 10px 0!important\n                        }\n                        .mobile-column td .text-1{ \n                            padding-top:10px!important;\n                            text-align: center!important;\n                        }\n                        .mobile-column td .text-2{ \n                            text-align: center!important;\n                        }\n                        .mobile-column td .counter{ \n                            width:55px!important;\n                            height:55px!important;\n                            min-height:55px!important;\n                            max-height:55px!important;\n                            text-align: center!important;\n                            margin:0 auto!important;\n                            font-size: 14px!important;\n                            line-height: 55px!important;\n                        }\n                        .mobile-column .upgrade-now-btn{ \n                            margin: 0 auto!important;\n                            display: inline-block!important;\n                            text-align: center!important;\n                            float: none!important;\n                            min-width: initial!important;\n                        }\n                        .mobile-column .column-1{ \n                           border:0!important;\n                        }\n                    }\n                \u003C\u002Fstyle\u003E\u003Cmeta charset=\"utf-8\"\u003E\u003C\u002Fhead\u003E\u003Cbody\u003E\n\u003Cp\u003E\u003Ca href=\"https:\u002F\u002Fform.jotform.com\u002F253562518664565?%7BpatientName%7D=%7BpatientFull%7D\" target=\"_blank\" rel=\"noopener noreferrer\"\u003Ehttps:\u002F\u002Fform.jotform.com\u002F253562518664565?{patientName}={patientFull}\u003C\u002Fa\u003E\u003Cimg src=\"https:\u002F\u002Fwww.jotform.com\u002Fuploads\u002Flesodecanalytics\u002Fform_files\u002FBlue%20and%20White%20Modern%20Medical%20Healthcare%20Presentation%20%281%29.6790c7d4b866b9.28462767.png\" alt=\"\" width=\"610\" height=\"343\"\u003E\u003C\u002Fp\u003E\n\u003Cp style=\"color: #000000; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 14px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;\"\u003EDear Dr. {consultingDoctor}\u003C\u002Fp\u003E\n\u003Cp style=\"color: #000000; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 14px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;\"\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp style=\"color: #000000; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 14px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;\"\u003EPlease see below appointment bookings for a patient and secure your availability.\u003C\u002Fp\u003E\n\u003Cp style=\"color: #000000; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 14px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;\"\u003EYour coorporation will be highly appreciated.\u003C\u002Fp\u003E\n\u003Cp style=\"color: #000000; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 14px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;\"\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp style=\"color: #000000; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 14px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;\"\u003E&nbsp;\u003C\u002Fp\u003E\n\u003Cp style=\"color: 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jsMobileErrorWrapper"></div><div class="jfQuestion-fields"><div class="jfField isFilled" aria-hidden="false"><select name="q18_beautezPharmacy" data-component="dropdown" required="" id="input_18" tabindex="-1" class="form-dropdown validate[required]" aria-labelledby="label_18"><option value="">Please Select</option><option value="BTZ001 Beautez Pharmacy Maseru Mall">BTZ001 Beautez Pharmacy Maseru Mall</option><option value="BTZ002 Beautez Pharmacy Lifestyle Centre">BTZ002 Beautez Pharmacy Lifestyle Centre</option><option value="BTZ003 Beautez Pharmacy NRH Mall">BTZ003 Beautez Pharmacy NRH Mall</option><option value="BTZ004 Beautez Pharmacy Ha-Foso">BTZ004 Beautez Pharmacy Ha-Foso</option><option value="BTZ005 NUTRIMED Maseru Mall">BTZ005 NUTRIMED Maseru Mall</option><option value=""></option></select><div class="jfInput-dropdown isDrawer" datatype="multiselect" role="presentation"><div class="jfDropdown-wrapper" tabindex="0" aria-haspopup="true" aria-labelledby="label_18 jfDropdown-chip-input_18"><div class="jfDropdown-chipContainer"><span class="jfDropdown-chip isSingle" id="jfDropdown-chip-input_18">Please Select</span></div><span class="jfDropdown-toggle"></span></div><div id="jfDropdown-optionList-18" class="jfDropdown-optionListWrapper forDrawer"><ul name="q18_beautezPharmacy" data-component="dropdown" required="" aria-labelledby="label_18" role="listbox" class="jfDropdown-optionList form-dropdown"><li role="option" data-value="Please Select" class="jfDropdown-optionListItem">Please Select</li><li role="option" data-value="BTZ001 Beautez Pharmacy Maseru Mall" class="jfDropdown-optionListItem">BTZ001 Beautez Pharmacy Maseru Mall</li><li role="option" data-value="BTZ002 Beautez Pharmacy Lifestyle Centre" class="jfDropdown-optionListItem">BTZ002 Beautez Pharmacy Lifestyle Centre</li><li role="option" data-value="BTZ003 Beautez Pharmacy NRH Mall" class="jfDropdown-optionListItem">BTZ003 Beautez Pharmacy NRH Mall</li><li role="option" data-value="BTZ004 Beautez Pharmacy Ha-Foso" class="jfDropdown-optionListItem">BTZ004 Beautez Pharmacy Ha-Foso</li><li role="option" data-value="BTZ005 NUTRIMED Maseru Mall" class="jfDropdown-optionListItem">BTZ005 NUTRIMED Maseru Mall</li><li role="option" data-value="" class="jfDropdown-optionListItem"></li></ul></div></div><label class="jfField-sublabel " for="input_18" aria-hidden="true" tabindex="-1"></label></div></div></div><div class="jfCard-actions"><button style="display:none" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_0">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_0">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_birthdate" id="id_39"><div id="cid_39" class="jfCard-wrapper"><div class="jfCard" data-type="control_birthdate"><div class="jfCard-index"><div>2</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><label for="input_39" class="jfQuestion-label isCenterAlign" id="label_39"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Date of Birth</span></label><span class="jfQuestion-description" id="id_39_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div class="jfQuestion-fields isCompoundField jfQuestion-fields-contentVisible" data-wrapper-react="true"><div class="jfField isFilled" data-wrapper-react="true" data-type="liteDate"><input type="date" id="input_39" class="form-textbox jfInput-input jfCardDateInput isHidden" data-age="" max="2100-12-30" aria-hidden="true" style="pointer-events:auto" value=""/><input id="lite_mode_39" class="form-textbox validate[validateLiteDate] jfCardDateInput jfInput-input" type="text" size="12" maxLength="12" data-format="mmddyyyy" required="" data-seperator="-" placeholder="mm-dd-yyyy" data-placeholder="mm-dd-yyyy" tabindex="0" data-age="" aria-required="false" value=""/><div class="isHidden"><span class="date-separate" aria-hidden="true">-</span></div><span style="display:flex" class="jfField-svgWrapper forDate" tabindex="0" role="button" aria-label="Open calendar to choose a date"><svg xmlns="http://www.w3.org/2000/svg" fill="currentColor" viewBox="0 0 24 24" style="width:24px;height:24px"><path fill-rule="evenodd" d="M8 1a1 1 0 0 1 1 1v1h6V2a1 1 0 1 1 2 0v1h2a3 3 0 0 1 3 3v14a3 3 0 0 1-3 3H5a3 3 0 0 1-3-3V6a3 3 0 0 1 3-3h2V2a1 1 0 0 1 1-1Zm12 5v3H4V6a1 1 0 0 1 1-1h2v1a1 1 0 0 0 2 0V5h6v1a1 1 0 1 0 2 0V5h2a1 1 0 0 1 1 1Zm-4.625 7.963c-.2-.391-.512-.587-.939-.587-.427 0-.743.196-.95.587-.198.39-.298 1.07-.298 2.037 0 .967.1 1.646.299 2.037.206.391.522.587.95.587.426 0 .739-.196.938-.587.206-.39.31-1.07.31-2.037 0-.967-.104-1.646-.31-2.037Zm1.387 5.098c-.505.626-1.28.939-2.326.939-1.045 0-1.824-.313-2.336-.939-.505-.625-.757-1.646-.757-3.061s.252-2.436.757-3.061c.512-.626 1.29-.939 2.336-.939 1.046 0 1.82.313 2.326.939.511.625.767 1.646.767 3.061s-.256 2.436-.767 3.061Zm-10.08-3.818-.15-.406a.875.875 0 0 1-.032-.522.886.886 0 0 1 .256-.448l1.43-1.344a1.512 1.512 0 0 1 1.045-.416h.683c.17 0 .312.06.426.181a.6.6 0 0 1 .17.427v6.57a.602.602 0 0 1-.17.427.562.562 0 0 1-.426.181H9.23a.602.602 0 0 1-.597-.608v-5.077h-.02l-1.28 1.184a.38.38 0 0 1-.363.107.39.39 0 0 1-.288-.256Z" clip-rule="evenodd"></path></svg></span><label class="jfField-sublabel " for="lite_mode_39" id="sublabel_input_39" aria-hidden="true" tabindex="-1"></label></div><div style="display:none"><div class="jfField  isHidden cf-valid-hidden" data-type="month"><input type="tel" id="month_39" name="q39_dateOf[month]" class="form-textbox jfInput-input hasSublabel" size="2" maxLength="2" data-maxlength="2" tabindex="-1" data-component="month" aria-required="false" aria-describedby="id_39_description" aria-labelledby="label_39 sublabel_39_month" value=""/><label class="jfField-sublabel " for="month_39" id="sublabel_39_month">Month</label></div><div class="jfField  isHidden cf-valid-hidden" data-type="day"><input type="tel" id="day_39" name="q39_dateOf[day]" class="form-textbox jfInput-input hasSublabel" size="2" maxLength="2" data-maxlength="2" tabindex="-1" data-component="day" aria-required="false" aria-describedby="id_39_description" aria-labelledby="label_39 sublabel_39_day" value=""/><label class="jfField-sublabel " for="day_39" id="sublabel_39_day">Day</label></div><div class="jfField  isHidden cf-valid-hidden" data-type="year"><input type="tel" id="year_39" name="q39_dateOf[year]" class="form-textbox jfInput-input hasSublabel" size="4" maxLength="4" data-maxlength="4" tabindex="-1" data-component="year" aria-required="false" aria-describedby="id_39_description" aria-labelledby="label_39 sublabel_39_year" value=""/><label class="jfField-sublabel " for="year_39" id="sublabel_39_year">Year</label></div></div><img loading="lazy" alt="Pick a Date" id="input_39_pick" style="display:none;vertical-align:middle" data-component="datetime"/><div class="jfCalendar-wrapper" role="dialog" aria-label="Calendar"><div id="calendar-container-39" class="jfCalendar-container"></div></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_1">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_1">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_dropdown" id="id_23"><div id="cid_23" class="jfCard-wrapper"><div class="jfCard" data-type="control_dropdown"><div class="jfCard-index"><div>3</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><label for="input_23" class="jfQuestion-label isCenterAlign" id="label_23"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Payment Mode</span></label><span class="jfQuestion-description" id="id_23_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div class="jfQuestion-fields"><div class="jfField isFilled" aria-hidden="false"><select name="q23_paymentMode" data-component="dropdown" id="input_23" tabindex="-1" class="form-dropdown" aria-labelledby="label_23"><option value="">Please Select</option><option value="Cash Payment" selected="">Cash Payment</option><option value="Medical Aid Payment">Medical Aid Payment</option><option value="LOYALAID PAY">LOYALAID PAY</option></select><div class="jfInput-dropdown isDrawer" datatype="multiselect" role="presentation"><div class="jfDropdown-wrapper" tabindex="0" aria-haspopup="true" aria-labelledby="label_23 jfDropdown-chip-input_23"><div class="jfDropdown-chipContainer"><span class="jfDropdown-chip isSingle" id="jfDropdown-chip-input_23">Cash Payment</span></div><span class="jfDropdown-toggle"></span></div><div id="jfDropdown-optionList-23" class="jfDropdown-optionListWrapper forDrawer"><ul name="q23_paymentMode" data-component="dropdown" aria-labelledby="label_23" role="listbox" class="jfDropdown-optionList form-dropdown"><li role="option" data-value="Please Select" class="jfDropdown-optionListItem">Please Select</li><li role="option" data-value="Cash Payment" class="jfDropdown-optionListItem">Cash Payment</li><li role="option" data-value="Medical Aid Payment" class="jfDropdown-optionListItem">Medical Aid Payment</li><li role="option" data-value="LOYALAID PAY" class="jfDropdown-optionListItem">LOYALAID PAY</li></ul></div></div><label class="jfField-sublabel " for="input_23" aria-hidden="true" tabindex="-1"></label></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_2">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_2">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_dropdown" id="id_24"><div id="cid_24" class="jfCard-wrapper"><div class="jfCard" data-type="control_dropdown"><div class="jfCard-index"><div>4</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><label for="input_24" class="jfQuestion-label isCenterAlign" id="label_24"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Select Your Medical Aid</span></label><span class="jfQuestion-description" id="id_24_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div class="jfQuestion-fields"><div class="jfField isFilled" aria-hidden="false"><select name="q24_selectYour" data-component="dropdown" id="input_24" tabindex="-1" class="form-dropdown" aria-labelledby="label_24"><option value="">Please Select</option><option value="LOYALAID DIGITAL PAY">LOYALAID DIGITAL PAY</option><option value="METROPOLITAN MEDICAL AID">METROPOLITAN MEDICAL AID</option><option value="LIBERTY MEDICAL AID">LIBERTY MEDICAL AID</option><option value="DISCOVERY MEDICAL AID">DISCOVERY MEDICAL AID</option><option value="VITALITY MEDICAL AID">VITALITY MEDICAL AID</option><option value="MOMENTUM">MOMENTUM</option><option value="FEDHEALTH MEDICAL AID">FEDHEALTH MEDICAL AID</option><option value="GEMS MEDICAL AID">GEMS MEDICAL AID</option><option value="MEDSHIELD MEDICAL AID">MEDSHIELD MEDICAL AID</option><option value="BANKMED MEDICAL AID">BANKMED MEDICAL AID</option><option value="BONITAS MEDICAL AID BON0979511">BONITAS MEDICAL AID BON0979511</option><option value="ENGEN MEDICAL AID">ENGEN MEDICAL AID</option><option value=""></option></select><div class="jfInput-dropdown hasSearch isDrawer" datatype="multiselect" role="presentation"><div class="jfDropdown-wrapper" tabindex="0" aria-haspopup="true" aria-labelledby="label_24 jfDropdown-chip-input_24"><div class="jfDropdown-chipContainer"><span class="jfDropdown-chip isSingle" id="jfDropdown-chip-input_24" style="display:none">Please Select</span><div class="jfDropdown-searchWrapper"><input class="form-textbox jfDropdown-search" name="dropdown_search" autoComplete="off" placeholder="Please Select" aria-label="Please Select" type="text" value="Please Select"/></div></div><span class="jfDropdown-toggle"></span></div><div id="jfDropdown-optionList-24" class="jfDropdown-optionListWrapper forDrawer"><ul name="q24_selectYour" data-component="dropdown" aria-labelledby="label_24" role="listbox" class="jfDropdown-optionList form-dropdown"><li role="option" data-value="Please Select" class="jfDropdown-optionListItem">Please Select</li><li role="option" data-value="LOYALAID DIGITAL PAY" class="jfDropdown-optionListItem">LOYALAID DIGITAL PAY</li><li role="option" data-value="METROPOLITAN MEDICAL AID" class="jfDropdown-optionListItem">METROPOLITAN MEDICAL AID</li><li role="option" data-value="LIBERTY MEDICAL AID" class="jfDropdown-optionListItem">LIBERTY MEDICAL AID</li><li role="option" data-value="DISCOVERY MEDICAL AID" class="jfDropdown-optionListItem">DISCOVERY MEDICAL AID</li><li role="option" data-value="VITALITY MEDICAL AID" class="jfDropdown-optionListItem">VITALITY MEDICAL AID</li><li role="option" data-value="MOMENTUM" class="jfDropdown-optionListItem">MOMENTUM</li><li role="option" data-value="FEDHEALTH MEDICAL AID" class="jfDropdown-optionListItem">FEDHEALTH MEDICAL AID</li><li role="option" data-value="GEMS MEDICAL AID" class="jfDropdown-optionListItem">GEMS MEDICAL AID</li><li role="option" data-value="MEDSHIELD MEDICAL AID" class="jfDropdown-optionListItem">MEDSHIELD MEDICAL AID</li><li role="option" data-value="BANKMED MEDICAL AID" class="jfDropdown-optionListItem">BANKMED MEDICAL AID</li><li role="option" data-value="BONITAS MEDICAL AID BON0979511" class="jfDropdown-optionListItem">BONITAS MEDICAL AID BON0979511</li><li role="option" data-value="ENGEN MEDICAL AID" class="jfDropdown-optionListItem">ENGEN MEDICAL AID</li><li role="option" data-value="" class="jfDropdown-optionListItem"></li></ul></div></div><label class="jfField-sublabel " for="input_24" aria-hidden="true" tabindex="-1"></label></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_3">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_3">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_radio" id="id_31"><div id="cid_31" class="jfCard-wrapper"><div class="jfCard" data-type="control_radio"><div class="jfCard-index"><div>5</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><label for="input_group_31" class="jfQuestion-label isCenterAlign" id="label_31"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Membership Status</span></label><span class="jfQuestion-description" id="id_31_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div role="group" id="input_group_31" aria-describedby="id_31_description" class="jfQuestion-fields form-single-column" data-component="radio"><div class="jfField form-radio-item"><label data-id="label_input_31_0" class="jfRadio withoutImage"><input type="radio" class="jfRadio-input form-radio" name="q31_membershipStatus" id="input_31_0" aria-describedby="label_31" value="Main Member"/><div class="jfRadio-label"><span class="jfRadio-customInput"><span class="jfRadio-customInputIcon"></span></span><img class="jfRadio-visual" alt="Radio" loading="lazy"/><span class="jfRadio-labelText">Main Member</span></div></label></div><div class="jfField form-radio-item"><label data-id="label_input_31_1" class="jfRadio withoutImage"><input type="radio" class="jfRadio-input form-radio" name="q31_membershipStatus" id="input_31_1" aria-describedby="label_31" value="Dependant"/><div class="jfRadio-label"><span class="jfRadio-customInput"><span class="jfRadio-customInputIcon"></span></span><img class="jfRadio-visual" alt="Radio" loading="lazy"/><span class="jfRadio-labelText">Dependant</span></div></label></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_4">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_4">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_number" id="id_28"><div id="cid_28" class="jfCard-wrapper"><div class="jfCard" data-type="control_number"><div class="jfCard-index"><div>6</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><label for="input_28" class="jfQuestion-label isCenterAlign" id="label_28"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Medical Aid Number</span></label><span class="jfQuestion-description" id="id_28_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div class="jfQuestion-fields"><div class="jfField" data-type="number"><input type="number" id="input_28" name="q28_medicalAid" data-type="input-number" class=" form-number-input form-textbox forNumber jfInput-input" size="310" placeholder="e.g., 23" data-component="number" step="any" aria-required="false" aria-describedby="id_28_description" aria-labelledby="label_28" value=""/><label class="jfField-sublabel " for="input_28" aria-hidden="true" tabindex="-1"></label></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_5">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_5">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_fullname" id="id_3" data-compound-hint=""><div id="cid_3" class="jfCard-wrapper"><div class="jfCard" data-type="control_fullname"><div class="jfCard-index"><div>7</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><label for="input_group_3" class="jfQuestion-label isCenterAlign" id="label_3"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Patient Name</span><span class="jfRequiredStar">* <span class="jfRequiredStar-message">This field is required.</span></span></label><span class="jfQuestion-description" id="id_3_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div class="jfQuestion-fields" data-wrapper-react="true" role="group" id="input_group_3"><div class="jfField isFilled" data-type="prefix" aria-hidden="false"><select data-component="prefix" id="prefix_3" tabindex="-1" name="q3_patientName[prefix]" class="dropdown-match-height form-dropdown validate[required]" autoComplete="section-input_3 honorific-prefix" aria-labelledby="label_3 sublabel_3_prefix"><option value="Mr." selected="">Mr.</option><option value="Mrs.">Mrs.</option><option value="Miss">Miss</option><option value="Dr.">Dr.</option><option value="Prof.">Prof.</option><option value=""></option></select><div class="jfInput-dropdown" datatype="multiselect" role="presentation"><div class="jfDropdown-wrapper" tabindex="0" aria-haspopup="true" aria-labelledby="label_3 sublabel_3_prefix jfDropdown-chip-prefix_3"><div class="jfDropdown-chipContainer"><span class="jfDropdown-chip isSingle" id="jfDropdown-chip-prefix_3">Mr.</span></div><span class="jfDropdown-toggle"></span></div><div id="jfDropdown-optionList-3-prefix" class="jfDropdown-optionListWrapper"><ul data-component="prefix" aria-labelledby="label_3 sublabel_3_prefix" role="listbox" class="jfDropdown-optionList form-dropdown"><li role="option" data-value="Mr." class="jfDropdown-optionListItem">Mr.</li><li role="option" data-value="Mrs." class="jfDropdown-optionListItem">Mrs.</li><li role="option" data-value="Miss" class="jfDropdown-optionListItem">Miss</li><li role="option" data-value="Dr." class="jfDropdown-optionListItem">Dr.</li><li role="option" data-value="Prof." class="jfDropdown-optionListItem">Prof.</li><li role="option" data-value="" class="jfDropdown-optionListItem"></li></ul></div></div><label class="jfField-sublabel " for="prefix_3" id="sublabel_3_prefix">Tittle</label></div><div class="jfField" data-type="first"><input type="text" id="first_3" name="q3_patientName[first]" class="form-textbox validate[required] forFullname jfInput-input hasSublabel" autoComplete="given-name" size="10" data-component="first" required="" aria-required="true" aria-describedby="id_3_description" aria-labelledby="label_3 sublabel_3_first" value=""/><label class="jfField-sublabel " for="first_3" id="sublabel_3_first">First Name</label></div><div class="jfField" data-type="last"><input type="text" id="last_3" name="q3_patientName[last]" class="form-textbox validate[required] forFullname jfInput-input hasSublabel" autoComplete="family-name" size="15" data-component="last" required="" aria-required="true" aria-describedby="id_3_description" aria-labelledby="label_3 sublabel_3_last" value=""/><label class="jfField-sublabel " for="last_3" id="sublabel_3_last">Last Name</label></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_6">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_6">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_phone" id="id_4" data-compound-hint=""><div id="cid_4" class="jfCard-wrapper"><div class="jfCard" data-type="control_phone"><div class="jfCard-index"><div>8</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><label for="input_group_4" class="jfQuestion-label isCenterAlign" id="label_4"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Patient Phone Number</span><span class="jfRequiredStar">* <span class="jfRequiredStar-message">This field is required.</span></span></label><span class="jfQuestion-description" id="id_4_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div class="jfQuestion-fields" data-wrapper-react="true" role="group" id="input_group_4"><div class="jfField" data-type="areaCode"><input type="tel" id="input_4_area" name="q4_patientPhone[area]" class="form-textbox validate[required] forPhone jfInput-input hasSublabel" autoComplete="tel-area-code" size="6" data-component="areaCode" required="" aria-required="true" aria-describedby="id_4_description" aria-labelledby="label_4 sublabel_4_area" value=""/><label class="jfField-sublabel " for="input_4_area" id="sublabel_4_area">Area Code</label></div><div class="jfField" data-type="phone"><input type="tel" id="input_4_phone" name="q4_patientPhone[phone]" class="form-textbox validate[required] forPhone jfInput-input hasSublabel" autoComplete="tel-local" size="12" data-component="phone" required="" aria-required="true" aria-describedby="id_4_description" aria-labelledby="label_4 sublabel_4_phone" value=""/><label class="jfField-sublabel " for="input_4_phone" id="sublabel_4_phone">Phone Number</label></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_7">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_7">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_textbox" id="id_43"><div id="cid_43" class="jfCard-wrapper"><div class="jfCard" data-type="control_textbox"><div class="jfCard-index"><div>9</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><label for="input_43" class="jfQuestion-label isCenterAlign" id="label_43"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Patient Identity Number</span></label><span class="jfQuestion-description" id="id_43_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div class="jfQuestion-fields"><div class="jfField" data-type="textbox"><input type="text" id="input_43" name="q43_identityNumber43" data-type="input-textbox" class="form-textbox jfInput-input" size="20" data-component="textbox" aria-required="false" aria-describedby="id_43_description" aria-labelledby="label_43" value=""/><label class="jfField-sublabel " for="input_43" aria-hidden="true" tabindex="-1"></label></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_8">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_8">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_email" id="id_5"><div id="cid_5" class="jfCard-wrapper"><div class="jfCard" data-type="control_email"><div class="jfCard-index"><div>10</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><label for="input_5" class="jfQuestion-label isCenterAlign" id="label_5"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Patient Email</span><span class="jfRequiredStar">* <span class="jfRequiredStar-message">This field is required.</span></span></label><span class="jfQuestion-description" id="id_5_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div class="jfQuestion-fields questionMode"><div class="jfField" data-type="email"><input type="email" id="input_5" name="q5_patientEmail" class="form-textbox validate[required, Email] forEmail jfInput-input hasSublabel" autoComplete="email" size="310" data-component="email" required="" aria-required="true" aria-describedby="id_5_description" aria-labelledby="label_5 sublabel_input_5" value=""/><label class="jfField-sublabel " for="input_5" id="sublabel_input_5">example@example.com</label><div class="jfCardTooltip js-tooltipContainer"><div class="js-tooltipMessageContainer-info"></div><div class="js-tooltipMessageContainer-error"></div><div class="jfCardTooltip-close js-tooltipCloseButton"><span class="iconSvg"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 326 326"><g data-name="Layer 2"><g data-name="Layer 1"><path class="fail-outer" d="M163,0C73.12,0,0,73.12,0,163S73.12,326,163,326s163-73.12,163-163S252.88,0,163,0Z"></path><path class="fail-inner" d="M227.6,98.4a14.75,14.75,0,0,0-20.86,0L163,142.14,119.26,98.4A14.75,14.75,0,1,0,98.4,119.26L142.14,163,98.4,206.74a14.75,14.75,0,1,0,20.86,20.86L163,183.86l43.74,43.74a14.75,14.75,0,1,0,20.86-20.86L183.86,163l43.74-43.74A14.75,14.75,0,0,0,227.6,98.4Z"></path></g></g></svg></span></div></div></div><div class="jfEmailVerify-loading"><span class="loadingDot"></span><span class="loadingDot isD2"></span><span class="loadingDot isD3"></span></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_9">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_9">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_dropdown" id="id_32"><div id="cid_32" class="jfCard-wrapper"><div class="jfCard" data-type="control_dropdown"><div class="jfCard-index"><div>11</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><label for="input_32" class="jfQuestion-label isCenterAlign" id="label_32"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Consulting Doctor</span></label><span class="jfQuestion-description" id="id_32_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div class="jfQuestion-fields"><div class="jfField isFilled" aria-hidden="false"><select name="q32_consultingDoctor32" data-component="dropdown" id="input_32" tabindex="-1" class="form-dropdown" aria-labelledby="label_32"><option value="">Please Select</option><option value="Dr. M.B Lelimo">Dr. M.B Lelimo</option><option value="Dr. M. Kolobe">Dr. M. Kolobe</option><option value="Dr. L. Letlala">Dr. L. Letlala</option><option value=""></option></select><div class="jfInput-dropdown isDrawer" datatype="multiselect" role="presentation"><div class="jfDropdown-wrapper" tabindex="0" aria-haspopup="true" aria-labelledby="label_32 jfDropdown-chip-input_32"><div class="jfDropdown-chipContainer"><span class="jfDropdown-chip isSingle" id="jfDropdown-chip-input_32">Please Select</span></div><span class="jfDropdown-toggle"></span></div><div id="jfDropdown-optionList-32" class="jfDropdown-optionListWrapper forDrawer"><ul name="q32_consultingDoctor32" data-component="dropdown" aria-labelledby="label_32" role="listbox" class="jfDropdown-optionList form-dropdown"><li role="option" data-value="Please Select" class="jfDropdown-optionListItem">Please Select</li><li role="option" data-value="Dr. M.B Lelimo" class="jfDropdown-optionListItem">Dr. M.B Lelimo</li><li role="option" data-value="Dr. M. Kolobe" class="jfDropdown-optionListItem">Dr. M. Kolobe</li><li role="option" data-value="Dr. L. Letlala" class="jfDropdown-optionListItem">Dr. L. Letlala</li><li role="option" data-value="" class="jfDropdown-optionListItem"></li></ul></div></div><label class="jfField-sublabel " for="input_32" aria-hidden="true" tabindex="-1"></label></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_10">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_10">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_email" id="id_16"><div id="cid_16" class="jfCard-wrapper"><div class="jfCard" data-type="control_email"><div class="jfCard-index"><div>12</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><label for="input_16" class="jfQuestion-label isCenterAlign" id="label_16"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Doctor Email</span><span class="jfRequiredStar">* <span class="jfRequiredStar-message">This field is required.</span></span></label><span class="jfQuestion-description" id="id_16_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div class="jfQuestion-fields questionMode"><div class="jfField" data-type="email"><input type="email" id="input_16" name="q16_doctorEmail" class="form-textbox validate[required, Email] forEmail jfInput-input hasSublabel" autoComplete="email" size="310" data-component="email" required="" aria-required="true" aria-describedby="id_16_description" aria-labelledby="label_16 sublabel_input_16" value=""/><label class="jfField-sublabel " for="input_16" id="sublabel_input_16">example@example.com</label><div class="jfCardTooltip js-tooltipContainer"><div class="js-tooltipMessageContainer-info"></div><div class="js-tooltipMessageContainer-error"></div><div class="jfCardTooltip-close js-tooltipCloseButton"><span class="iconSvg"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 326 326"><g data-name="Layer 2"><g data-name="Layer 1"><path class="fail-outer" d="M163,0C73.12,0,0,73.12,0,163S73.12,326,163,326s163-73.12,163-163S252.88,0,163,0Z"></path><path class="fail-inner" d="M227.6,98.4a14.75,14.75,0,0,0-20.86,0L163,142.14,119.26,98.4A14.75,14.75,0,1,0,98.4,119.26L142.14,163,98.4,206.74a14.75,14.75,0,1,0,20.86,20.86L163,183.86l43.74,43.74a14.75,14.75,0,1,0,20.86-20.86L183.86,163l43.74-43.74A14.75,14.75,0,0,0,227.6,98.4Z"></path></g></g></svg></span></div></div></div><div class="jfEmailVerify-loading"><span class="loadingDot"></span><span class="loadingDot isD2"></span><span class="loadingDot isD3"></span></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_11">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_11">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_radio" id="id_6"><div id="cid_6" class="jfCard-wrapper"><div class="jfCard" data-type="control_radio"><div class="jfCard-index"><div>13</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><label for="input_group_6" class="jfQuestion-label isCenterAlign" id="label_6"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Types of Consultation</span><span class="jfRequiredStar">* <span class="jfRequiredStar-message">This field is required.</span></span></label><span class="jfQuestion-description" id="id_6_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div role="group" id="input_group_6" aria-describedby="id_6_description" class="jfQuestion-fields form-single-column" data-component="radio"><div class="jfField form-radio-item"><label data-id="label_input_6_0" class="jfRadio withoutImage"><input type="radio" class="jfRadio-input form-radio validate[required]" name="q6_typesOf" id="input_6_0" required="" aria-describedby="label_6" value="Diagnostic consultation"/><div class="jfRadio-label"><span class="jfRadio-customInput"><span class="jfRadio-customInputIcon"></span></span><img class="jfRadio-visual" alt="Radio" loading="lazy"/><span class="jfRadio-labelText">Diagnostic consultation</span></div></label></div><div class="jfField form-radio-item"><label data-id="label_input_6_1" class="jfRadio withoutImage"><input type="radio" class="jfRadio-input form-radio validate[required]" name="q6_typesOf" id="input_6_1" required="" aria-describedby="label_6" value="Remote consultation"/><div class="jfRadio-label"><span class="jfRadio-customInput"><span class="jfRadio-customInputIcon"></span></span><img class="jfRadio-visual" alt="Radio" loading="lazy"/><span class="jfRadio-labelText">Remote consultation</span></div></label></div><div class="jfField form-radio-item"><label data-id="label_input_6_2" class="jfRadio withoutImage"><input type="radio" class="jfRadio-input form-radio validate[required]" name="q6_typesOf" id="input_6_2" required="" aria-describedby="label_6" value="Primary care consultation"/><div class="jfRadio-label"><span class="jfRadio-customInput"><span class="jfRadio-customInputIcon"></span></span><img class="jfRadio-visual" alt="Radio" loading="lazy"/><span class="jfRadio-labelText">Primary care consultation</span></div></label></div><div class="jfField form-radio-item"><label data-id="label_input_6_3" class="jfRadio withoutImage"><input type="radio" class="jfRadio-input form-radio validate[required]" name="q6_typesOf" id="input_6_3" required="" aria-describedby="label_6" value="Mental health support"/><div class="jfRadio-label"><span class="jfRadio-customInput"><span class="jfRadio-customInputIcon"></span></span><img class="jfRadio-visual" alt="Radio" loading="lazy"/><span class="jfRadio-labelText">Mental health support</span></div></label></div><div class="jfField form-radio-item"><label data-id="label_input_6_4" class="jfRadio withoutImage"><input type="radio" class="jfRadio-input form-radio validate[required]" name="q6_typesOf" id="input_6_4" required="" aria-describedby="label_6" value="Psychoanalytic or Psychodynamic Therapy"/><div class="jfRadio-label"><span class="jfRadio-customInput"><span class="jfRadio-customInputIcon"></span></span><img class="jfRadio-visual" alt="Radio" loading="lazy"/><span class="jfRadio-labelText">Psychoanalytic or Psychodynamic Therapy</span></div></label></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_12">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_12">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line jf-required" data-type="control_widget" id="id_7"><div id="cid_7" class="jfCard-wrapper"><div class="jfCard" data-type="control_widget"><div class="jfCard-index"><div>14</div></div><div class="jfCard-question" data-widget-id="533946093c1ad0c45d000070"><label for="input_7" class="jfQuestion-label isCenterAlign" id="label_7"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Medical History</span><span class="jfRequiredStar">* <span class="jfRequiredStar-message">This field is required.</span></span></label><span class="jfQuestion-description" id="id_7_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div class="jfQuestion-fields"><div class="jfField jfWidget form-input" dataType="textbox" data-widget-id="533946093c1ad0c45d000070"><div class="jfWidget-frame" style="text-align:left" data-component="widget-field"><iframe frameBorder="0" scrolling="yes" allowtransparency="true" allow="geolocation; microphone; camera; autoplay; encrypted-media; fullscreen" data-type="iframe" class="custom-field-frame" id="customFieldFrame_7" title="Configurable List" src="" style="border:none;width:650px;height:130px" data-width="650" data-height="130"></iframe><div class="widget-inputs-wrapper"><input id="input_7" class="form-hidden form-widget widget-required " type="hidden" name="q7_medicalHistory" value=""/><input id="widget_settings_7" class="form-hidden form-widget-settings" type="hidden" data-version="2" value="%5B%7B%22name%22%3A%22fields%22%2C%22value%22%3A%22Diagnosis%2F%20Allergies%20%3A%20textarea%20%3A%20Hint%20Text%5CnMedicines%20if%20taken%20%3A%20textarea%20%3A%20Hint%20Text%5CnStill%20Using%3F%20%3A%20dropdown%20%3A%20Yes%2C%20No%20%3A%20Please%20Select%5CnAdditional%20Notes%20%3A%20textarea%20%3A%20If%20you%20want%20to%20add%20any%20comment%2C%20please%20write%20here.%22%7D%2C%7B%22name%22%3A%22minRowsNumber%22%2C%22value%22%3A%221%22%7D%2C%7B%22name%22%3A%22limit%22%2C%22value%22%3A%220%22%7D%2C%7B%22name%22%3A%22customCSS%22%2C%22value%22%3A%22.checkbox%2C%20.radio%20%7B%5Cnmargin%3A%203px%200%3B%5Cnmin-width%3A%2070px%3B%5Cn%7D%22%7D%2C%7B%22name%22%3A%22labelAdd%22%2C%22value%22%3A%22%2B%22%7D%2C%7B%22name%22%3A%22labelRemove%22%2C%22value%22%3A%22x%22%7D%2C%7B%22name%22%3A%22isTableView%22%2C%22value%22%3A%22Yes%22%7D%5D"/></div></div></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_13">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_13">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_inline" id="id_41"><div id="cid_41" class="jfCard-wrapper"><div class="jfCard" data-type="control_inline"><div class="jfCard-index"><div>15</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div class="jfQuestion-fields"><div id="FITB_41" class="FITB formRender"><p>Resp Patten 
    <span data-type="textbox" class="FITB-inptCont" data-grouptype="control_textbox" data-blot-id="shorttext-1">
      <input class="form-textbox " name="q41_input41[shorttext-1]" id="41_shorttext-1" type="text" required />
      <label for="41_shorttext-1">blanks</label>
      
    </span> <br />Spo2 
    <span data-type="textbox" class="FITB-inptCont" data-grouptype="control_textbox" data-blot-id="shorttext-2">
      <input class="form-textbox " name="q41_input41[shorttext-2]" id="41_shorttext-2" type="text" required />
      <label for="41_shorttext-2">blank</label>
      
    </span> %.  <br />Temp
    <span data-type="textbox" class="FITB-inptCont" data-grouptype="control_number" data-blot-id="number-3">
      <input class="form-textbox form-number-input validate[]" name="q41_input41[number-3]" id="41_number-3" type="number" required />
      <label for="41_number-3"></label>
      
    </span>Celcious</p></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_14">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_14">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_inline" id="id_42"><div id="cid_42" class="jfCard-wrapper"><div class="jfCard" data-type="control_inline"><div class="jfCard-index"><div>16</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div class="jfQuestion-fields"><div id="FITB_42" class="FITB formRender"><p>Blood Pressure 
    <span data-type="textbox" class="FITB-inptCont" data-grouptype="control_textbox" data-blot-id="shorttext-1">
      <input class="form-textbox " name="q42_input42[shorttext-1]" id="42_shorttext-1" type="text" required />
      <label for="42_shorttext-1">blanks</label>
      
    </span>mmHg<br />Pulse Rate 
    <span data-type="textbox" class="FITB-inptCont" data-grouptype="control_textbox" data-blot-id="shorttext-2">
      <input class="form-textbox " name="q42_input42[shorttext-2]" id="42_shorttext-2" type="text" required />
      <label for="42_shorttext-2">blank</label>
      
    </span> bpm<br />RBS
    <span data-type="textbox" class="FITB-inptCont" data-grouptype="control_number" data-blot-id="number-3">
      <input class="form-textbox form-number-input validate[]" name="q42_input42[number-3]" id="42_number-3" type="number" required />
      <label for="42_number-3"></label>
      
    </span>%</p></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_15">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_15">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_textarea" id="id_9"><div id="cid_9" class="jfCard-wrapper"><div class="jfCard" data-type="control_textarea"><div class="jfCard-index"><div>17</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><label for="input_9" class="jfQuestion-label isCenterAlign" id="label_9"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Additional Medical Notes</span></label><span class="jfQuestion-description" id="id_9_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div class="jfQuestion-fields" data-component="textarea"><div class="jfField" data-type="textarea"><textarea id="input_9" class="jfInput-textarea form-textarea" data-component="textarea" rows="4" cols="648" name="q9_additionalMedical"></textarea><label class="jfField-sublabel " for="input_9" aria-hidden="true" tabindex="-1"></label></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_16">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_16">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_phone" id="id_17" data-compound-hint=""><div id="cid_17" class="jfCard-wrapper"><div class="jfCard" data-type="control_phone"><div class="jfCard-index"><div>18</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><label for="input_group_17" class="jfQuestion-label isCenterAlign" id="label_17"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Phone Number</span><span class="jfRequiredStar">* <span class="jfRequiredStar-message">This field is required.</span></span></label><span class="jfQuestion-description" id="id_17_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div class="jfQuestion-fields" data-wrapper-react="true" role="group" id="input_group_17"><div class="jfField" data-type="areaCode"><input type="tel" id="input_17_area" name="q17_phoneNumber17[area]" class="form-textbox validate[required] forPhone jfInput-input hasSublabel" autoComplete="tel-area-code" size="6" data-component="areaCode" required="" aria-required="true" aria-describedby="id_17_description" aria-labelledby="label_17 sublabel_17_area" value=""/><label class="jfField-sublabel " for="input_17_area" id="sublabel_17_area">Area Code</label></div><div class="jfField" data-type="phone"><input type="tel" id="input_17_phone" name="q17_phoneNumber17[phone]" class="form-textbox validate[required] forPhone jfInput-input hasSublabel" autoComplete="tel-local" size="12" data-component="phone" required="" aria-required="true" aria-describedby="id_17_description" aria-labelledby="label_17 sublabel_17_phone" value=""/><label class="jfField-sublabel " for="input_17_phone" id="sublabel_17_phone">Phone Number</label></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_17">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_17">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_dropdown" id="id_44"><div id="cid_44" class="jfCard-wrapper"><div class="jfCard" data-type="control_dropdown"><div class="jfCard-index"><div>19</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><label for="input_44" class="jfQuestion-label isCenterAlign" id="label_44"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Appointment Date &amp; Time</span></label><span class="jfQuestion-description" id="id_44_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div class="jfQuestion-fields"><div class="jfField isFilled" aria-hidden="false"><select name="q44_appointmentDate" data-component="dropdown" id="input_44" tabindex="-1" class="form-dropdown" aria-labelledby="label_44"><option value="">Please Select</option><option value="Consult Doctor Now.">Consult Doctor Now.</option><option value="Book Appointment With  a Doctor">Book Appointment With  a Doctor</option></select><div class="jfInput-dropdown isDrawer" datatype="multiselect" role="presentation"><div class="jfDropdown-wrapper" tabindex="0" aria-haspopup="true" aria-labelledby="label_44 jfDropdown-chip-input_44"><div class="jfDropdown-chipContainer"><span class="jfDropdown-chip isSingle" id="jfDropdown-chip-input_44">Please Select</span></div><span class="jfDropdown-toggle"></span></div><div id="jfDropdown-optionList-44" class="jfDropdown-optionListWrapper forDrawer"><ul name="q44_appointmentDate" data-component="dropdown" aria-labelledby="label_44" role="listbox" class="jfDropdown-optionList form-dropdown"><li role="option" data-value="Please Select" class="jfDropdown-optionListItem">Please Select</li><li role="option" data-value="Consult Doctor Now." class="jfDropdown-optionListItem">Consult Doctor Now.</li><li role="option" data-value="Book Appointment With  a Doctor" class="jfDropdown-optionListItem">Book Appointment With  a Doctor</li></ul></div></div><label class="jfField-sublabel " for="input_44" aria-hidden="true" tabindex="-1"></label></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_18">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_18">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line always-hidden" data-type="control_fullname" id="id_14" data-compound-hint=""><div id="cid_14" class="jfCard-wrapper"><div class="jfCard" data-type="control_fullname"><div class="jfCard-index"><div>20</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><label for="input_group_14" class="jfQuestion-label isCenterAlign" id="label_14"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Consulting Doctor</span><span class="jfRequiredStar">* <span class="jfRequiredStar-message">This field is required.</span></span></label><span class="jfQuestion-description" id="id_14_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div class="jfQuestion-fields" data-wrapper-react="true" role="group" id="input_group_14"><div class="jfField" data-type="first"><input type="text" id="first_14" name="q14_consultingDoctor[first]" class="form-textbox validate[required] forFullname jfInput-input hasSublabel" autoComplete="given-name" size="10" data-component="first" required="" aria-required="true" aria-describedby="id_14_description" aria-labelledby="label_14 sublabel_14_first" value=""/><label class="jfField-sublabel " for="first_14" id="sublabel_14_first">First Name</label></div><div class="jfField" data-type="last"><input type="text" id="last_14" name="q14_consultingDoctor[last]" class="form-textbox validate[required] forFullname jfInput-input hasSublabel" autoComplete="family-name" size="15" data-component="last" required="" aria-required="true" aria-describedby="id_14_description" aria-labelledby="label_14 sublabel_14_last" value=""/><label class="jfField-sublabel " for="last_14" id="sublabel_14_last">Last Name</label></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_19">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_19">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_appointment" id="id_10"><div id="cid_10" class="jfCard-wrapper"><div class="jfCard" data-type="control_appointment"><div class="jfCard-index"><div>21</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><label for="input_10" class="jfQuestion-label isCenterAlign" id="label_10"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Please Select an Appointment Date</span><span class="jfRequiredStar">* <span class="jfRequiredStar-message">This field is required.</span></span></label><span class="jfQuestion-description" id="id_10_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div id="input_10" class="appointmentFieldWrapper jfQuestion-fields"><input class="appointmentFieldInput" name="q10_pleaseSelect[implementation]" id="input_10implementation" aria-hidden="true" type="hidden" value="new"/><input class="appointmentFieldInput validate" name="q10_pleaseSelect[date]" id="input_10_date" data-timeformat="24 Hour" aria-hidden="true" type="hidden"/><input class="appointmentFieldInput" name="q10_pleaseSelect[duration]" id="input_10_duration" aria-hidden="true" type="hidden" value="30"/><input class="appointmentFieldInput" name="q10_pleaseSelect[timezone]" id="input_10_timezone" aria-hidden="true" type="hidden" value="Africa/Johannesburg (GMT+02:00)"/><div class="appointmentField"></div></div></div><div class="jfCard-actions"><button style="display:block" type="button" class="jfInput-button forPrev u-left" data-component="button" aria-label="Previous" data-testid="previousButton_20">Previous</button><button style="display:block" type="button" class="jfInput-button forNext u-right" data-component="button" aria-label="Next" data-testid="nextButton_20">Next</button><button style="display:none" type="submit" class="jfInput-button forSubmit form-submit-button u-right legacy-submit" data-component="button" aria-label="Submit" data-testid="submitButton">Submit</button><div class="cf"><div class="jfCard-actionsNotification" aria-live="polite"><div class="jfPressEnter isHidden" aria-hidden="true">Press<br/>Enter</div></div></div><div class="jfCard-disableSubmitError"></div></div></div></div></li><li class="form-line" data-type="control_fileupload" id="id_19"><div id="cid_19" class="jfCard-wrapper"><div class="jfCard" data-type="control_fileupload"><div class="jfCard-index"><div>22</div></div><div class="jfCard-question"><div class="jfQuestion-fullscreen isHidden" aria-hidden="true" role="button" aria-label="fullscreen mode" tabindex="-1"></div><label for="input_19" class="jfQuestion-label isCenterAlign" id="label_19"><span class="jsQuestionLabelContainer jfQuestionLabelContainer" role="heading" aria-level="2">Attach Patient Documents</span></label><span class="jfQuestion-description" id="id_19_description"><span></span></span><div class="jfCard-mobileError jsMobileErrorWrapper"></div><div class="jfQuestion-fields" data-wrapper-react="true"><div class="jfField isFilled"><div class="jfUpload-wrapper"><div class="jfUpload-container"><div class="jfUpload-text-container"><div class="jfUpload-icon forDesktop"><svg width="54px" height="47px" viewBox="0 0 54 47" version="1.1" xmlns="http://www.w3.org/2000/svg"><g stroke="none" stroke-width="1" fill="none"><g transform="translate(-1506.000000, -2713.000000)"><g transform="translate(1421.000000, 2713.000000)"><path d="M125.212886,10.1718048 C127.110227,10.3826204 128.89335,10.9096517 130.562307,11.7529143 C132.231264,12.596177 133.689384,13.676591 134.93671,14.9941889 C136.184036,16.3117868 137.167828,17.8226097 137.888114,19.5267029 C138.608401,21.2307962 138.968539,23.049054 138.968539,24.9815309 C138.968539,26.8086 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