{"id":13981,"date":"2015-12-10T13:33:19","date_gmt":"2015-12-10T13:33:19","guid":{"rendered":"https:\/\/bellicapelliforum.com\/?page_id=13981"},"modified":"2016-09-26T09:42:26","modified_gmt":"2016-09-26T09:42:26","slug":"consultation-2","status":"publish","type":"page","link":"https:\/\/bellicapelliforum.com\/en\/consultation-2\/","title":{"rendered":"CONSULTATION"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_10' style='display:none'><div id='gf_10' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">VIRTUAL CONSULTATION<\/h3>\n                            <p class='gform_description'>Through this form you will be able to receive an evaluation and a quotation from the clinics mentioned below. Please check your spam folder if you don't receive a reply within 7 days. The fields marked with a \"*\" must be filled out.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_10'  action='\/en\/wp-json\/wp\/v2\/pages\/13981#gf_10' data-formid='10' novalidate>\n        <div id='gf_progressbar_wrapper_10' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>3<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_33' style='width:33%;'><span>33%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_10_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_10' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><li id=\"field_10_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"00c53b1a\" data-field-span=\"12\"><label id='gfield_label_10_1' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name and Surname<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_10_1'>\n                            <span id='input_10_1_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_1.2' id='input_10_1_2'    aria-required='false'   aria-labelledby=\"input_10_1_2_label gfield_label_10_1\">\n                          <option value=''><\/option><option value='Mr.' >Mr.<\/option><option value='Mrs.' >Mrs.<\/option><option value='Miss' >Miss<\/option><option value='Ms.' >Ms.<\/option><option value='Dr.' >Dr.<\/option><option value='Prof.' >Prof.<\/option><option value='Rev.' >Rev.<\/option>\n                      <\/select>\n                                                    <label for='input_10_1_2' id='input_10_1_2_label' class='gform-field-label gform-field-label--type-sub '>Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_10_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_10_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_10_1_3' id='input_10_1_3_label' class='gform-field-label gform-field-label--type-sub '>Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_10_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_10_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_10_1_6' id='input_10_1_6_label' class='gform-field-label gform-field-label--type-sub '>Surname<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_10_2\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"ef5655dd\" data-field-span=\"12\"><label id='gfield_label_10_2' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip has_country ginput_container_address gform-grid-row' id='input_10_2' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_10_2_1_container' >\n                                        <input type='text' name='input_2.1' id='input_10_2_1' value=''    aria-required='true'    aria-labelledby=\"input_10_2_1_label gfield_label_10_2\"\/>\n                                        <label for='input_10_2_1' id='input_10_2_1_label' class='gform-field-label gform-field-label--type-sub '>Street + number<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_10_2_3_container' >\n                                    <input type='text' name='input_2.3' id='input_10_2_3' value=''    aria-required='true'    \/>\n                                    <label for='input_10_2_3' id='input_10_2_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_2.4' id='input_10_2_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_10_2_5_container' >\n                                    <input type='text' name='input_2.5' id='input_10_2_5' value=''    aria-required='true'    \/>\n                                    <label for='input_10_2_5' id='input_10_2_5_label' class='gform-field-label gform-field-label--type-sub '>Zip code<\/label>\n                                <\/span><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_10_2_6_container' >\n                                        <select name='input_2.6' id='input_10_2_6'   aria-required='true'    ><option value='' ><\/option><option value='AF' >Afghanistan<\/option><option value='AX' >\u00c5land Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='CV' >Cabo Verde<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Democratic Republic of the<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='CI' >C\u00f4te d&#039;Ivoire<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czechia<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >Eswatini<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='VA' >Holy See<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='KP' >Korea, Democratic People&#039;s Republic of<\/option><option value='KR' >Korea, Republic of<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Lao People&#039;s Democratic Republic<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='MK' >North Macedonia<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PS' >Palestine, State of<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='RE' >R\u00e9union<\/option><option value='RO' >Romania<\/option><option value='RU' >Russian Federation<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='SH' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='MF' >Saint Martin<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SX' >Sint Maarten<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia and the South Sandwich Islands<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria Arab Republic<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania, the United Republic of<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >T\u00fcrkiye<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom<\/option><option value='US' >United States<\/option><option value='UY' >Uruguay<\/option><option value='UM' >US Minor Outlying Islands<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Viet Nam<\/option><option value='VG' >Virgin Islands, British<\/option><option value='VI' >Virgin Islands, U.S.<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select>\n                                        <label for='input_10_2_6' id='input_10_2_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_10_3\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"28f8c065\" data-field-span=\"12\"><label id='gfield_label_10_3' class='gfield_label gform-field-label' for='input_10_3'><span class='gform-field-label__text'>Telephone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_10_3' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_10_3\"   \/><\/div><div class='gfield_description' id='gfield_description_10_3'>Insert your telephone number<\/div><\/li><li id=\"field_10_4\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"d1069d1c\" data-field-span=\"12\"><label id='gfield_label_10_4' class='gfield_label gform-field-label' for='input_10_4'><span class='gform-field-label__text'>Date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='dd\/mm\/yyyy'\n\t\t\t\t\tid='input_10_4'\n\t\t\t\t\tclass='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_4'\n\t\t\t\t\tvalue=''\n\t\t\t\t\taria-describedby=\"gfield_description_10_4\" \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_10_4' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_10_4' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_10_4' aria-label='Date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><div class='gfield_description' id='gfield_description_10_4'>Insert your date of birth<\/div><\/li><li id=\"field_10_5\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"8631a159\" data-field-span=\"12\"><label id='gfield_label_10_5' class='gfield_label gform-field-label' for='input_10_5'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_10_5' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_10_5\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_10_5'>Insert the e-mail address where you would like to receive the evaluation<\/div><\/li><li id=\"field_10_6\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"68cafcee\" data-field-span=\"12\"><label id='gfield_label_10_6' class='gfield_label gform-field-label' for='input_10_6'><span class='gform-field-label__text'>Do you use Finasteride ?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_10_6' class='medium gfield_select'  aria-describedby=\"gfield_description_10_6\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Never Used' selected='selected'>Never Used<\/option><option value='Stopped using due to side effects' >Stopped using due to side effects<\/option><option value='Currently using a frequently as perscribed' >Currently using a frequently as perscribed<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_10_6'>Please specify if you are using Finasteride (Propecia or Proscar)<\/div><\/li><li id=\"field_10_7\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"9b5714f3\" data-field-span=\"12\"><label id='gfield_label_10_7' class='gfield_label gform-field-label' for='input_10_7'><span class='gform-field-label__text'>Do you use Minoxidil ?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_10_7' class='medium gfield_select'  aria-describedby=\"gfield_description_10_7\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Never Used' >Never Used<\/option><option value='Stopped using less than 2 months ago due to side effects' >Stopped using less than 2 months ago due to side effects<\/option><option value='Currently using as frequently as prescribed' >Currently using as frequently as prescribed<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_10_7'>Please specify if you are using Minoxidil<\/div><\/li><li id=\"field_10_8\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"badc08f5\" data-field-span=\"12\"><label id='gfield_label_10_8' class='gfield_label gform-field-label' for='input_10_8'><span class='gform-field-label__text'>Have you undergone a hair transplant surgery in the past ?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_8' id='input_10_8' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_10_9\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"ff4f92aa\" data-field-span=\"12\"><label id='gfield_label_10_9' class='gfield_label gform-field-label' for='input_10_9'><span class='gform-field-label__text'>Which surgical tecnique has been used during your previous surgery ?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_9' id='input_10_9' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Fut - They removed a strip from the back of my scalp' selected='selected'>Fut - They removed a strip from the back of my scalp<\/option><option value='FUE- Follicles have been extracted one by one using a punch' >FUE- Follicles have been extracted one by one using a punch<\/option><option value='BHT - Follicles have been extracted from the body\/beard' >BHT - Follicles have been extracted from the body\/beard<\/option><\/select><\/div><\/li><li id=\"field_10_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"32edfb11\" data-field-span=\"12\"><label id='gfield_label_10_10' class='gfield_label gform-field-label' for='input_10_10'><span class='gform-field-label__text'>Year of your previous surgery<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text' data-text-counter-max='20' data-text-counter-template='{current} of {max} max characters'><input name='input_10' id='input_10_10' type='text' value='' class='medium' maxlength='20'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"352b6f2b\" data-field-span=\"12\"><label id='gfield_label_10_11' class='gfield_label gform-field-label' for='input_10_11'><span class='gform-field-label__text'>How many grafts did you receive in your previous surgery ?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text' data-text-counter-max='100' data-text-counter-template='{current} of {max} max characters'><input name='input_11' id='input_10_11' type='text' value='' class='medium' maxlength='100' aria-describedby=\"gfield_description_10_11\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_10_11'>Please insert a value between 100 and 7500<\/div><\/li><li id=\"field_10_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"9270863e\" data-field-span=\"12\"><label id='gfield_label_10_12' class='gfield_label gform-field-label' for='input_10_12'><span class='gform-field-label__text'>Which doctor performed your previous surgery ?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text' data-text-counter-max='150' data-text-counter-template='{current} of {max} max characters'><input name='input_12' id='input_10_12' type='text' value='' class='medium' maxlength='150'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_13\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"a08c159f\" data-field-span=\"12\"><label id='gfield_label_10_13' class='gfield_label gform-field-label' for='input_10_13'><span class='gform-field-label__text'>Have you undergone more than one hair transplant surgery in the past ?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_13' id='input_10_13' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='YES' selected='selected'>YES<\/option><option value='NO' >NO<\/option><\/select><\/div><\/li><li id=\"field_10_14\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"1474dfac\" data-field-span=\"12\"><label id='gfield_label_10_14' class='gfield_label gform-field-label' for='input_10_14'><span class='gform-field-label__text'>Please give us as many details as possible of your previous surgeries (number of grafts, technique used, doctor who performed the surgery)<\/span><\/label><div class='ginput_container ginput_container_textarea' data-text-counter-max='200' data-text-counter-template='{current} of {max} max characters'><textarea name='input_14' id='input_10_14' class='textarea medium'   maxlength='200'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <button type='button' id='gform_next_button_10_15' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_10_2' class='gform_page' data-js='page-field-id-15' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_10_2' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><li id=\"field_10_16\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"31e45ba3\" data-field-span=\"12\"><a href=\"http:\/\/s279.photobucket.com\/user\/BIBIANELLA\/media\/scalp-zones-bg_zpsc314087f.png.html\" target=\"_blank\"><img decoding=\"async\" src=\"http:\/\/i279.photobucket.com\/albums\/kk131\/BIBIANELLA\/scalp-zones-bg_zpsc314087f.png\" border=\"0\" alt=\" photo scalp-zones-bg_zpsc314087f.png\"\/><\/a><\/li><li id=\"field_10_17\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"72e0f90b\" data-field-span=\"12\"><label id='gfield_label_10_17' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Which areas of your scalp would you like to restore ?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_10_17'><li class='gchoice gchoice_10_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='Zone 1 - Temples'  id='choice_10_17_1'   aria-describedby=\"gfield_description_10_17\" aria-labelledby=\"label_10_17_1 gfield_label_10_17\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_10_17_1' id='label_10_17_1' class='gform-field-label gform-field-label--type-inline'>Zone 1 - Temples<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='Zone 2 - Hairline'  id='choice_10_17_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_17_2' id='label_10_17_2' class='gform-field-label gform-field-label--type-inline'>Zone 2 - Hairline<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_17_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.3' type='checkbox'  value='Zone 3 - Forelock'  id='choice_10_17_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_17_3' id='label_10_17_3' class='gform-field-label gform-field-label--type-inline'>Zone 3 - Forelock<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_17_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.4' type='checkbox'  value='Zone 4 - Mid scalp'  id='choice_10_17_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_17_4' id='label_10_17_4' class='gform-field-label gform-field-label--type-inline'>Zone 4 - Mid scalp<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_17_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.5' type='checkbox'  value='Zone 5-6-7 Crown\/Vertex'  id='choice_10_17_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_17_5' id='label_10_17_5' class='gform-field-label gform-field-label--type-inline'>Zone 5-6-7 Crown\/Vertex<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_10_17'>Please check the image above and select the areas that you would like to restore<\/div><\/li><li id=\"field_10_18\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"0f3498da\" data-field-span=\"12\"><label id='gfield_label_10_18' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Which clinic\/surgeon would you like to contact ?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_10_18'><li class='gchoice gchoice_10_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='Hasson&amp;Wong (Strip\/FUE - Canada)'  id='choice_10_18_1'    aria-labelledby=\"label_10_18_1 gfield_label_10_18\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_1' id='label_10_18_1' class='gform-field-label gform-field-label--type-inline'>Hasson&amp;Wong (Strip\/FUE - Canada)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='Dr.Rahal (FUE - Canada)'  id='choice_10_18_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_2' id='label_10_18_2' class='gform-field-label gform-field-label--type-inline'>Dr.Rahal (FUE - Canada)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='Dr.Felipe Pittella (FUE-Brazil)'  id='choice_10_18_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_3' id='label_10_18_3' class='gform-field-label gform-field-label--type-inline'>Dr.Felipe Pittella (FUE-Brazil)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.4' type='checkbox'  value='Dr.Zarev (FUE-Bulgaria)'  id='choice_10_18_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_4' id='label_10_18_4' class='gform-field-label gform-field-label--type-inline'>Dr.Zarev (FUE-Bulgaria)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.5' type='checkbox'  value='ASMED CLINIC - Dr.Koray (FUE - Turkey)'  id='choice_10_18_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_5' id='label_10_18_5' class='gform-field-label gform-field-label--type-inline'>ASMED CLINIC - Dr.Koray (FUE - Turkey)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.6' type='checkbox'  value='Dr.Ulusan|Medicalhair (FUE\/BHT-Turkiye)'  id='choice_10_18_6'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_6' id='label_10_18_6' class='gform-field-label gform-field-label--type-inline'>Dr.Ulusan|Medicalhair (FUE\/BHT-Turkiye)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.7' type='checkbox'  value='Hairline Clinic (HLC) (FUE\/ BHT - Turkey)'  id='choice_10_18_7'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_7' id='label_10_18_7' class='gform-field-label gform-field-label--type-inline'>Hairline Clinic (HLC) (FUE\/ BHT - Turkey)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.8' type='checkbox'  value='Dr.Serkan Aygin (FUE\/BHT - Turkey)'  id='choice_10_18_8'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_8' id='label_10_18_8' class='gform-field-label gform-field-label--type-inline'>Dr.Serkan Aygin (FUE\/BHT - Turkey)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.9' type='checkbox'  value='Dr.Gizem K|Estpital (FUE - Turkey)'  id='choice_10_18_9'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_9' id='label_10_18_9' class='gform-field-label gform-field-label--type-inline'>Dr.Gizem K|Estpital (FUE - Turkey)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.11' type='checkbox'  value='Murat Makasci Clinic (FUE\/BHT-Turkey)'  id='choice_10_18_11'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_11' id='label_10_18_11' class='gform-field-label gform-field-label--type-inline'>Murat Makasci Clinic (FUE\/BHT-Turkey)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.12' type='checkbox'  value='Smilehairclinic (FUE\/BHT - Turkey)'  id='choice_10_18_12'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_12' id='label_10_18_12' class='gform-field-label gform-field-label--type-inline'>Smilehairclinic (FUE\/BHT - Turkey)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.13' type='checkbox'  value='Dr.Kaan Pekiner (FUE - Turkey)'  id='choice_10_18_13'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_13' id='label_10_18_13' class='gform-field-label gform-field-label--type-inline'>Dr.Kaan Pekiner (FUE - Turkey)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.14' type='checkbox'  value='Dr.Altan-Aestepool Clinic (FUE - Turkey)'  id='choice_10_18_14'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_14' id='label_10_18_14' class='gform-field-label gform-field-label--type-inline'>Dr.Altan-Aestepool Clinic (FUE - Turkey)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.15' type='checkbox'  value='Medblue Clinic - Dr.Turan (FUE-Turkey)'  id='choice_10_18_15'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_15' id='label_10_18_15' class='gform-field-label gform-field-label--type-inline'>Medblue Clinic - Dr.Turan (FUE-Turkey)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.16' type='checkbox'  value='NDB clinic (FUE-Turkey)'  id='choice_10_18_16'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_16' id='label_10_18_16' class='gform-field-label gform-field-label--type-inline'>NDB clinic (FUE-Turkey)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.17' type='checkbox'  value='Dr.Ozlem Bi\u00e7er (FUE-Turkey)'  id='choice_10_18_17'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_17' id='label_10_18_17' class='gform-field-label gform-field-label--type-inline'>Dr.Ozlem Bi\u00e7er (FUE-Turkey)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.18' type='checkbox'  value='Dr.Resul Yaman (FUE\/BHT - Turkey)'  id='choice_10_18_18'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_18' id='label_10_18_18' class='gform-field-label gform-field-label--type-inline'>Dr.Resul Yaman (FUE\/BHT - Turkey)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.19' type='checkbox'  value='Dr.Bircan (FUE - Turkey)'  id='choice_10_18_19'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_19' id='label_10_18_19' class='gform-field-label gform-field-label--type-inline'>Dr.Bircan (FUE - Turkey)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.21' type='checkbox'  value='Dr.Fatma Dursun (FUE -Turkey)'  id='choice_10_18_21'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_21' id='label_10_18_21' class='gform-field-label gform-field-label--type-inline'>Dr.Fatma Dursun (FUE -Turkey)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.22' type='checkbox'  value='Zeynep Metin Clinic (FUE - Turkey)'  id='choice_10_18_22'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_22' id='label_10_18_22' class='gform-field-label gform-field-label--type-inline'>Zeynep Metin Clinic (FUE - Turkey)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.23' type='checkbox'  value='Aisha Hair Transplant (FUE-Turkey)'  id='choice_10_18_23'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_23' id='label_10_18_23' class='gform-field-label gform-field-label--type-inline'>Aisha Hair Transplant (FUE-Turkey)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.24' type='checkbox'  value='Aramedica Clinic (FUE -Turkey)'  id='choice_10_18_24'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_24' id='label_10_18_24' class='gform-field-label gform-field-label--type-inline'>Aramedica Clinic (FUE -Turkey)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.25' type='checkbox'  value='Dr.Keser- Dermaplast (FUE - Turkey)'  id='choice_10_18_25'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_25' id='label_10_18_25' class='gform-field-label gform-field-label--type-inline'>Dr.Keser- Dermaplast (FUE - Turkey)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.26' type='checkbox'  value='Dr.De Freitas (FUE - Spain)'  id='choice_10_18_26'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_26' id='label_10_18_26' class='gform-field-label gform-field-label--type-inline'>Dr.De Freitas (FUE - Spain)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.27' type='checkbox'  value='Dr.Feriduni (Strip\/FUE\/BHT - Belgium)'  id='choice_10_18_27'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_27' id='label_10_18_27' class='gform-field-label gform-field-label--type-inline'>Dr.Feriduni (Strip\/FUE\/BHT - Belgium)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.28' type='checkbox'  value='Medikemos Clinic - Dr.Lupanzula (FUE \/ BHT - Belgium)'  id='choice_10_18_28'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_28' id='label_10_18_28' class='gform-field-label gform-field-label--type-inline'>Medikemos Clinic - Dr.Lupanzula (FUE \/ BHT - Belgium)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.29' type='checkbox'  value='Hattingen Hair (Strip\/FUE- Switzerland)'  id='choice_10_18_29'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_29' id='label_10_18_29' class='gform-field-label gform-field-label--type-inline'>Hattingen Hair (Strip\/FUE- Switzerland)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.31' type='checkbox'  value='Insparya Clinic (FUE - Italy)'  id='choice_10_18_31'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_31' id='label_10_18_31' class='gform-field-label gform-field-label--type-inline'>Insparya Clinic (FUE - Italy)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.32' type='checkbox'  value='Aramedica Lecce (FUE - Italy)'  id='choice_10_18_32'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_32' id='label_10_18_32' class='gform-field-label gform-field-label--type-inline'>Aramedica Lecce (FUE - Italy)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.33' type='checkbox'  value='Dr.Chiara Insalaco (FUE - Italy)'  id='choice_10_18_33'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_33' id='label_10_18_33' class='gform-field-label gform-field-label--type-inline'>Dr.Chiara Insalaco (FUE - Italy)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_10_18_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.34' type='checkbox'  value='Dr.Vincenzo Masullo (FUE - Italy)'  id='choice_10_18_34'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_34' id='label_10_18_34' class='gform-field-label gform-field-label--type-inline'>Dr.Vincenzo Masullo (FUE - Italy)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_10_19\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"75153e2c\" data-field-span=\"12\"><label id='gfield_label_10_19' class='gfield_label gform-field-label' for='input_10_19'><span class='gform-field-label__text'>When would you like to have your surgery ?<\/span><\/label><div class='ginput_container ginput_container_text' data-text-counter-max='140' data-text-counter-template='{current} of {max} max characters'><input name='input_19' id='input_10_19' type='text' value='' class='medium' maxlength='140'     aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_10_20' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_10_20' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_10_3' class='gform_page' data-js='page-field-id-20' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_10_3' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><li id=\"field_10_21\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"bfa1546a\" data-field-span=\"12\"><b>PAGE 3 - PICTURES:<\/b>\n\nPictures should be preferably taken with your face uncovered. Your privacy is guaranteed and the pictures will only be kept in the clinic database. \n\nIt's very import that you take the pictures following these rules:\n\n<b>DON'T USE FLASH <\/b>\n\n<b>TAKE YOUR PICTURES FROM A DISTANCE OF 80 CM - 1 METER (32 - 40 INCHES)\n<\/b>\n\n<b>PREFERABLY TAKE YOUR PICTURES WITH A DIGITAL CAMERA NOT WITH A WEBCAM NOR A CELLPHONE WITH LOW RESOLUTION<\/b>\n\n<b>TRY TO FOCUS ON THE BALD, THINNED AREAS AND DON'T COVER THEM<\/b>\n\n<b>TAKE YOUR PHOTOS IN EXTERIORS UNDER NATURAL LIGHT<\/b>\n\nPoses are very important, and the following images are needed:\n\n<b>FRONTAL VIEW<\/b> - Show at least your eyebrows\n\n<center>\n<a href=\"http:\/\/s279.photobucket.com\/user\/BIBIANELLA\/media\/Febbraino%202012\/hairline.jpg.html\" target=\"_blank\"><img decoding=\"async\" src=\"http:\/\/i279.photobucket.com\/albums\/kk131\/BIBIANELLA\/Febbraino%202012\/hairline.jpg\" border=\"0\" alt=\" photo hairline.jpg\"\/><\/a>\n<\/center>\n<b> COMPLETE\nLEFT AND RIGHT SIDE<\/b>\n\n<center>\n<a href=\"http:\/\/s279.photobucket.com\/user\/BIBIANELLA\/media\/Febbraino%202012\/profiles.jpg.html\" target=\"_blank\"><img decoding=\"async\" src=\"http:\/\/i279.photobucket.com\/albums\/kk131\/BIBIANELLA\/Febbraino%202012\/profiles.jpg\" border=\"0\" alt=\" photo profiles.jpg\"\/><\/a>\n<\/center>\n\n<b>COMPLETE TOP VIEW<\/b>\n\n<center>\n<a href=\"http:\/\/s279.photobucket.com\/user\/BIBIANELLA\/media\/Febbraino%202012\/top.jpg.html\" target=\"_blank\"><img decoding=\"async\" src=\"http:\/\/i279.photobucket.com\/albums\/kk131\/BIBIANELLA\/Febbraino%202012\/top.jpg\" border=\"0\" alt=\" photo top.jpg\"\/><\/a>\n<\/center>\n\n<b>COMPLETE VIEW OF THE DONOR AREA<\/b> \n\n<center>\n<a href=\"http:\/\/s279.photobucket.com\/user\/BIBIANELLA\/media\/Febbraino%202012\/back.jpg.html\" target=\"_blank\"><img decoding=\"async\" src=\"http:\/\/i279.photobucket.com\/albums\/kk131\/BIBIANELLA\/Febbraino%202012\/back.jpg\" border=\"0\" alt=\" photo back.jpg\"\/><\/a>\n<\/center><\/li><li id=\"field_10_22\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"f7de7c47\" data-field-span=\"12\"><label id='gfield_label_10_22' class='gfield_label gform-field-label' for='input_10_22'><span class='gform-field-label__text'>FRONT VIEW<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='268435456' \/><input name='input_22' id='input_10_22' type='file' class='medium' aria-describedby=\"gfield_upload_rules_10_22 gfield_description_10_22\" onchange='javascript:gformValidateFileSize( this, 268435456 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_10_22'>Accepted file types: jpg, jpeg, gif, tiff, png, bmp, Max. file size: 256 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_10_22'><\/div> <\/div><div class='gfield_description' id='gfield_description_10_22'>Show at least your eyebrows<\/div><\/li><li id=\"field_10_23\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"cafe0396\" data-field-span=\"12\"><label id='gfield_label_10_23' class='gfield_label gform-field-label' for='input_10_23'><span class='gform-field-label__text'>LEFT SIDE<\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='268435456' \/><input name='input_23' id='input_10_23' type='file' class='medium' aria-describedby=\"gfield_upload_rules_10_23\" onchange='javascript:gformValidateFileSize( this, 268435456 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_10_23'>Accepted file types: jpg, jpeg, png, bmp, gif, tiff, Max. file size: 256 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_10_23'><\/div> <\/div><\/li><li id=\"field_10_24\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"2c4f46c8\" data-field-span=\"12\"><label id='gfield_label_10_24' class='gfield_label gform-field-label' for='input_10_24'><span class='gform-field-label__text'>RIGHT SIDE PICTURE<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='268435456' \/><input name='input_24' id='input_10_24' type='file' class='medium' aria-describedby=\"gfield_upload_rules_10_24\" onchange='javascript:gformValidateFileSize( this, 268435456 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_10_24'>Accepted file types: jpg, jpeg, gif, tiff, png, Max. file size: 256 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_10_24'><\/div> <\/div><\/li><li id=\"field_10_25\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"59c99019\" data-field-span=\"12\"><label id='gfield_label_10_25' class='gfield_label gform-field-label' for='input_10_25'><span class='gform-field-label__text'>TOP VIEW PICTURE<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='268435456' \/><input name='input_25' id='input_10_25' type='file' class='medium' aria-describedby=\"gfield_upload_rules_10_25\" onchange='javascript:gformValidateFileSize( this, 268435456 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_10_25'>Accepted file types: jpg, jpeg, gif, tiff, png, bp, Max. file size: 256 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_10_25'><\/div> <\/div><\/li><li id=\"field_10_26\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"09e58476\" data-field-span=\"12\"><label id='gfield_label_10_26' class='gfield_label gform-field-label' for='input_10_26'><span class='gform-field-label__text'>BACK VIEW (DONOR AREA PICTURE)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='268435456' \/><input name='input_26' id='input_10_26' type='file' class='medium' aria-describedby=\"gfield_upload_rules_10_26\" onchange='javascript:gformValidateFileSize( this, 268435456 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_10_26'>Accepted file types: jpg, jpeg, gif, png, tiff, bmp, Max. file size: 256 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_10_26'><\/div> <\/div><\/li><li id=\"field_10_27\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"2bb96b26\" data-field-span=\"12\"><label id='gfield_label_10_27' class='gfield_label gform-field-label' for='input_10_27'><span class='gform-field-label__text'>EXTRA PICTURE<\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='268435456' \/><input name='input_27' id='input_10_27' type='file' class='medium' aria-describedby=\"gfield_upload_rules_10_27 gfield_description_10_27\" onchange='javascript:gformValidateFileSize( this, 268435456 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_10_27'>Accepted file types: jpg, jpeg, tiff, gif, png, bmp, Max. file size: 256 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_10_27'><\/div> <\/div><div class='gfield_description' id='gfield_description_10_27'>Do you have another picture that you want to show to the doctor ? Please upload it !<\/div><\/li><li id=\"field_10_28\" class=\"gfield gfield--type-captcha gfield--input-type-captcha field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"6799ce5c\" data-field-span=\"12\"><label id='gfield_label_10_28' class='gfield_label gform-field-label' for='input_10_28'><span class='gform-field-label__text'>Captcha<\/span><\/label><div id='input_10_28' class='ginput_container ginput_recaptcha' data-sitekey='6Ldf4ScUAAAAAC4ol5K5Yy5pcsGdLfa6dli619pZ'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/li><\/ul><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><button type='submit' id='gform_previous_button_10' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='submit' id='gform_submit_button_10' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Invia<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_10' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_10' id='gform_theme_10' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_10' id='gform_style_settings_10' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_10' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='10' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='Q\/M90KCqFI49t5UrQsiFYz556L0rVtOy9\/QqdGtd09aAqmTFPxDALzsMRpYf57hvWyBP+C1yfCSgQibvPoUWey74eQ8MSOigyYnCNxjUg794Mtg=' \/>\n            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