{"id":5808,"date":"2026-05-07T05:37:00","date_gmt":"2026-05-07T05:37:00","guid":{"rendered":"https:\/\/telescopecenter.com\/?page_id=5808"},"modified":"2026-06-08T11:44:33","modified_gmt":"2026-06-08T11:44:33","slug":"medical-tourism-form","status":"publish","type":"page","link":"https:\/\/telescopecenter.com\/ar\/medical-tourism-form\/","title":{"rendered":"Medical Tourism form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"5808\" class=\"elementor elementor-5808\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7e49265 e-con-full e-flex e-con e-parent\" data-id=\"7e49265\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;shape_divider_bottom&quot;:&quot;curve&quot;}\">\n\t\t\t\t<div class=\"elementor-shape elementor-shape-bottom\" aria-hidden=\"true\" data-negative=\"false\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 1000 100\" 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100%;\n}\n\n\/* ========================= FLOATING PLACEHOLDER ========================= *\/\n.custom-placeholder {\n    position: absolute;\n    left: 14px;\n    top: 50%;\n    transform: translateY(-50%);\n    pointer-events: none;\n    transition: 0.3s ease;\n    background: #fff;\n    padding: 0 6px;\n    z-index: 3;\n    font-family: \"Alexandria\", sans-serif;\n    font-size: 18px;\n    font-weight: 400;\n    line-height: 22px;\n    color: #000;\n}\n\n\/* ACTIVE STATE *\/\n.field-wrapper.active .custom-placeholder {\n    display: none;\n}\n\n\/* INPUT FIX *\/\n.elementor-field {\n    position: relative;\n    z-index: 2;\n    background: transparent;\n}\n\n\/* Fix iOS \/ Android UI overlap *\/\ninput[type=\"date\"], input.clockpicker {\n    appearance: none;\n    -webkit-appearance: none;\n    background-color: transparent;\n}\n\n.flatpickr-time {\n    display: none !important;\n}\n\n@media(max-width: 768px){\n    .custom-placeholder {\n        font-size: 16px;\n    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========================== *\/\n        scope.find('input[type=\"date\"]').each(function(){\n            let input = $(this);\n            if (!input.parent().hasClass('field-wrapper')) {\n                input.wrap('<div class=\"field-wrapper\"><\/div>');\n                input.after('<span class=\"custom-placeholder\">' + (input.attr('placeholder') || 'Date Of Birth') + '<\/span>');\n            }\n\n            let wrapper = input.parent();\n\n            function updateState(){\n                if(input.val()){\n                    wrapper.addClass('active');\n                } else {\n                    wrapper.removeClass('active');\n                }\n            }\n\n            input.on('focus click', () => wrapper.addClass('active'));\n            input.on('blur', () => setTimeout(updateState,100));\n            input.on('input change', updateState);\n            updateState();\n        });\n    }\n\n    \/\/ Elementor hook\n    $(window).on('elementor\/frontend\/init', function () {\n        elementorFrontend.hooks.addAction('frontend\/element_ready\/form.default', initFields);\n    });\n})(jQuery);\n<\/script>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7d6a231 derma-form elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"7d6a231\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"International Patients\u2019 Form\" aria-label=\"International Patients\u2019 Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"5808\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"7d6a231\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Medical Tourism form - Telescope Medical Center\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"5808\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_a406c65 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_7a9fd3e elementor-col-100\">\n\t\t\t\t\tPersonal Information\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tFull Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Full Name\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-dateofbirth elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dateofbirth\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tDate Of Birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[dateofbirth]\" id=\"form-field-dateofbirth\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" placeholder=\"Date Of Birth\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-gender elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-gender\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tGender\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[gender]\" id=\"form-field-gender\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Gender <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\" Male\">Male <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\" Female\">Female <\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-searchcountry elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-searchcountry\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tCountry of Residence\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[searchcountry]\" id=\"form-field-searchcountry\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Select Country<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Afghanistan\">Afghanistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Albania\">Albania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Algeria\">Algeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Andorra\">Andorra<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Angola\">Angola<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Argentina\">Argentina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Armenia\">Armenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Australia\">Australia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Austria\">Austria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Azerbaijan\">Azerbaijan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bahamas\">Bahamas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bahrain\">Bahrain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bangladesh\">Bangladesh<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Barbados\">Barbados<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Belarus\">Belarus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Belgium\">Belgium<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Belize\">Belize<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Benin\">Benin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bhutan\">Bhutan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bolivia\">Bolivia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Botswana\">Botswana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Brazil\">Brazil<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Brunei\">Brunei<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bulgaria\">Bulgaria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Burkina Faso\">Burkina Faso<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Burundi\">Burundi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cambodia\">Cambodia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cameroon\">Cameroon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Canada\">Canada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cape Verde\">Cape Verde<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Central African Republic\">Central African 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Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"East Timor\">East Timor<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ecuador\">Ecuador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Egypt\">Egypt<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"El Salvador\">El Salvador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Equatorial Guinea\">Equatorial Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Eritrea\">Eritrea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Estonia\">Estonia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Eswatini\">Eswatini<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ethiopia\">Ethiopia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Fiji\">Fiji<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Finland\">Finland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"France\">France<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Gabon\">Gabon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Gambia\">Gambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Georgia\">Georgia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Germany\">Germany<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ghana\">Ghana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Greece\">Greece<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Grenada\">Grenada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guatemala\">Guatemala<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guinea\">Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guinea-Bissau\">Guinea-Bissau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guyana\">Guyana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Haiti\">Haiti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Honduras\">Honduras<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hungary\">Hungary<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Iceland\">Iceland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"India\">India<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Indonesia\">Indonesia<\/option>\n\t\t\t\t\t\t\t\t\t<option 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value=\"Lesotho\">Lesotho<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Liberia\">Liberia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Libya\">Libya<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Liechtenstein\">Liechtenstein<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lithuania\">Lithuania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Luxembourg\">Luxembourg<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Madagascar\">Madagascar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Malawi\">Malawi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Malaysia\">Malaysia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Maldives\">Maldives<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mali\">Mali<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Malta\">Malta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Marshall Islands\">Marshall Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mauritania\">Mauritania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mauritius\">Mauritius<\/option>\n\t\t\t\t\t\t\t\t\t<option 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value=\"Qatar\">Qatar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Romania\">Romania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Russia\">Russia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Rwanda\">Rwanda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saint Lucia\">Saint Lucia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Samoa\">Samoa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"San Marino\">San Marino<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saudi Arabia\">Saudi Arabia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Senegal\">Senegal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Serbia\">Serbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Seychelles\">Seychelles<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sierra Leone\">Sierra Leone<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Singapore\">Singapore<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Slovakia\">Slovakia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Slovenia\">Slovenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Solomon Islands\">Solomon Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Somalia\">Somalia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Africa\">South Africa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Korea\">South Korea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Sudan\">South Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Spain\">Spain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sri Lanka\">Sri Lanka<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sudan\">Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Suriname\">Suriname<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sweden\">Sweden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Switzerland\">Switzerland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Syria\">Syria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Taiwan\">Taiwan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tajikistan\">Tajikistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tanzania\">Tanzania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Thailand\">Thailand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Togo\">Togo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tonga\">Tonga<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tunisia\">Tunisia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Turkey\">Turkey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Turkmenistan\">Turkmenistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tuvalu\">Tuvalu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Uganda\">Uganda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ukraine\">Ukraine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"United Arab Emirates\">United Arab Emirates<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"United Kingdom\">United Kingdom<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"United States\">United States<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Uruguay\">Uruguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Uzbekistan\">Uzbekistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vanuatu\">Vanuatu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vatican City\">Vatican City<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Venezuela\">Venezuela<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vietnam\">Vietnam<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yemen\">Yemen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Zambia\">Zambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Zimbabwe\">Zimbabwe<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-searchnationality elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-searchnationality\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tNationality\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[searchnationality]\" id=\"form-field-searchnationality\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Select Nationality<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Afghan\">Afghan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Albanian\">Albanian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Algerian\">Algerian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"American\">American<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Andorran\">Andorran<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Angolan\">Angolan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Argentine\">Argentine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Armenian\">Armenian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Australian\">Australian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Austrian\">Austrian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bangladeshi\">Bangladeshi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Belgian\">Belgian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Brazilian\">Brazilian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"British\">British<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bulgarian\">Bulgarian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cambodian\">Cambodian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Canadian\">Canadian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Chinese\">Chinese<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Colombian\">Colombian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Croatian\">Croatian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cuban\">Cuban<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Czech\">Czech<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Danish\">Danish<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dutch\">Dutch<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Egyptian\">Egyptian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"English\">English<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ethiopian\">Ethiopian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Finnish\">Finnish<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"French\">French<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"German\">German<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Greek\">Greek<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hungarian\">Hungarian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Indian\">Indian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Indonesian\">Indonesian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Iranian\">Iranian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Iraqi\">Iraqi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Irish\">Irish<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Israeli\">Israeli<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Italian\">Italian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Jamaican\">Jamaican<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Japanese\">Japanese<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Jordanian\">Jordanian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kenyan\">Kenyan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kuwaiti\">Kuwaiti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lebanese\">Lebanese<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Libyan\">Libyan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Malaysian\">Malaysian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mexican\">Mexican<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Moroccan\">Moroccan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nepali\">Nepali<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Zealander\">New Zealander<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nigerian\">Nigerian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Norwegian\">Norwegian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pakistani\">Pakistani<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Palestinian\">Palestinian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Peruvian\">Peruvian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Philippine\">Philippine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Polish\">Polish<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Portuguese\">Portuguese<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Qatari\">Qatari<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Romanian\">Romanian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Russian\">Russian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saudi\">Saudi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Scottish\">Scottish<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Serbian\">Serbian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Singaporean\">Singaporean<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South African\">South African<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Korean\">South Korean<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Spanish\">Spanish<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sri Lankan\">Sri Lankan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Swedish\">Swedish<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Swiss\">Swiss<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Syrian\">Syrian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Taiwanese\">Taiwanese<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Thai\">Thai<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Turkish\">Turkish<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ukrainian\">Ukrainian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Uruguayan\">Uruguayan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Venezuelan\">Venezuelan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vietnamese\">Vietnamese<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Welsh\">Welsh<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yemeni\">Yemeni<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Zimbabwean\">Zimbabwean<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-passportnumber elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-passportnumber\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPassport Number (Optional)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[passportnumber]\" id=\"form-field-passportnumber\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Passport Number (Optional)\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_787be91 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_e2ab447 elementor-col-100\">\n\t\t\t\t\tContact Information\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-phonenumber elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-phonenumber\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPhone Number (Including Country Code)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<span class=\"ccfef-editor-intl-input\" data-id=\"form-field-phonenumber\" data-field-id=\"74eaf26\" data-default-country=\"in\" data-include-countries=\"\" data-exclude-countries=\"\" data-dial-code-visibility=\"show\" data-strict-mode=\"\" style=\"display: none;\"><\/span>\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[phonenumber]\" id=\"form-field-phonenumber\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Phone Number (Including Country Code)\" required=\"required\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-whatsappnumber elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-whatsappnumber\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tWhatsApp Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<span class=\"ccfef-editor-intl-input\" data-id=\"form-field-whatsappnumber\" data-field-id=\"b9817c5\" data-default-country=\"in\" data-include-countries=\"\" data-exclude-countries=\"\" data-dial-code-visibility=\"show\" data-strict-mode=\"no\" style=\"display: none;\"><\/span>\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[whatsappnumber]\" id=\"form-field-whatsappnumber\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"WhatsApp Number\" required=\"required\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-emailaddress elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-emailaddress\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEmail Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[emailaddress]\" id=\"form-field-emailaddress\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Email Address\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-contactmethod elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-contactmethod\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPreferred Contact Method\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[contactmethod]\" id=\"form-field-contactmethod\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Preferred Contact Method <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\" Phone\">Phone <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\" WhatsApp\">WhatsApp <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\" Email\">Email <\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_3b32dd9 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_371977b elementor-col-100\">\n\t\t\t\t\tMedical Information\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-requestedservice elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-requestedservice\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tRequested Department \/ Service\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[requestedservice]\" id=\"form-field-requestedservice\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Requested Department \/ Service <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\" Ophthalmology\">Ophthalmology <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\" Dermatology\">Dermatology <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\" Aesthetics\">Aesthetics <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\" Nutrition &amp; Body Contouring\">Nutrition &amp; Body Contouring <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\" Hair Transplant\">Hair Transplant <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\" Other\">Other <\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-medicalcondition elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalcondition\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tMain Concern \/ Medical Condition\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[medicalcondition]\" id=\"form-field-medicalcondition\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Main Concern \/ Medical Condition\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-previousmedicalhistory elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-previousmedicalhistory\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPrevious Medical History (Optional)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[previousmedicalhistory]\" id=\"form-field-previousmedicalhistory\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Previous Medical History (Optional)\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-previoussurgeries elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-previoussurgeries\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPrevious Surgeries or Procedures (Optional)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[previoussurgeries]\" id=\"form-field-previoussurgeries\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Previous Surgeries or Procedures (Optional)\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-currentmedications elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-currentmedications\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tCurrent Medications (Optional)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[currentmedications]\" id=\"form-field-currentmedications\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Current Medications (Optional)\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-allergies elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-allergies\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tAllergies (if any)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[allergies]\" id=\"form-field-allergies\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Allergies (if any)\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_095a4cd elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_e1967c1 elementor-col-100\">\n\t\t\t\t\tTravel Information\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-preffereddate elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-preffereddate\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPreferred Travel Dates (Optional)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[preffereddate]\" id=\"form-field-preffereddate\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" placeholder=\"Preferred Travel Dates (Optional)\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-estimatedlengthofstay elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-estimatedlengthofstay\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEstimated Length of Stay (Optional)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[estimatedlengthofstay]\" id=\"form-field-estimatedlengthofstay\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Estimated Length of Stay (Optional)\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-numberofaccompanyingpersons elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-numberofaccompanyingpersons\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tNumber of Accompanying Persons (Optional)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[numberofaccompanyingpersons]\" id=\"form-field-numberofaccompanyingpersons\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Number of Accompanying Persons (Optional)\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_f8afa39 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_b1fcd9d elementor-col-100\">\n\t\t\t\t\tPreferred Support Services\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-selectallcheckboxes elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" Full Medical Tourism Experience\" id=\"form-field-selectallcheckboxes-0\" name=\"form_fields[selectallcheckboxes][]\"> <label for=\"form-field-selectallcheckboxes-0\">Full Medical Tourism Experience <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" Visa Assistance\" id=\"form-field-selectallcheckboxes-1\" name=\"form_fields[selectallcheckboxes][]\"> <label for=\"form-field-selectallcheckboxes-1\">Visa Assistance <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" Airport Reception &amp; Transfer\" id=\"form-field-selectallcheckboxes-2\" name=\"form_fields[selectallcheckboxes][]\"> <label for=\"form-field-selectallcheckboxes-2\">Airport Reception & Transfer <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" Accommodation Arrangements\" id=\"form-field-selectallcheckboxes-3\" name=\"form_fields[selectallcheckboxes][]\"> <label for=\"form-field-selectallcheckboxes-3\">Accommodation Arrangements <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" Transportation Services\" id=\"form-field-selectallcheckboxes-4\" name=\"form_fields[selectallcheckboxes][]\"> <label for=\"form-field-selectallcheckboxes-4\">Transportation Services <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" Translation Support\" id=\"form-field-selectallcheckboxes-5\" name=\"form_fields[selectallcheckboxes][]\"> <label for=\"form-field-selectallcheckboxes-5\">Translation Support <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_066e42f elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_a8e78d4 elementor-col-100\">\n\t\t\t\t\tMedical Reports & Images\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-medicalreports elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalreports\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tMedical reports\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[medicalreports]\" id=\"form-field-medicalreports\" class=\"elementor-field elementor-size-sm  elementor-upload-field\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-prescriptions elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-prescriptions\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPrescriptions\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[prescriptions]\" id=\"form-field-prescriptions\" class=\"elementor-field elementor-size-sm  elementor-upload-field\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-laboratoryresults elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-laboratoryresults\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tLaboratory results\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[laboratoryresults]\" id=\"form-field-laboratoryresults\" class=\"elementor-field elementor-size-sm  elementor-upload-field\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-xraysscans elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-xraysscans\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tScans & Imaging\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[xraysscans]\" id=\"form-field-xraysscans\" class=\"elementor-field elementor-size-sm  elementor-upload-field\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-photosrelatedtotheconsition elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-photosrelatedtotheconsition\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPhotos related to the condition\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[photosrelatedtotheconsition]\" id=\"form-field-photosrelatedtotheconsition\" class=\"elementor-field elementor-size-sm  elementor-upload-field\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_6cefdd8 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_130c87a elementor-col-100\">\n\t\t\t\t\tAdditional Notes\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-additionalinformation elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-additionalinformation\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tAny additional information or requests (Optional)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[additionalinformation]\" id=\"form-field-additionalinformation\" rows=\"2\" placeholder=\"Any additional information or requests (Optional)\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-acceptence elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" I confirm that the information provided is accurate.\" id=\"form-field-acceptence-0\" name=\"form_fields[acceptence][]\"> <label for=\"form-field-acceptence-0\">I confirm that the information provided is accurate. <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" I consent to being contacted by Telescope Medical Center regarding my medical inquiry.\" id=\"form-field-acceptence-1\" name=\"form_fields[acceptence][]\"> <label for=\"form-field-acceptence-1\">I consent to being contacted by Telescope Medical Center regarding my medical inquiry. <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" I understand that all shared information will be handled confidentially.\" id=\"form-field-acceptence-2\" name=\"form_fields[acceptence][]\"> <label for=\"form-field-acceptence-2\">I understand that all shared information will be handled confidentially. <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t\t\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10\" height=\"10\" viewBox=\"0 0 10 10\" fill=\"none\"><path d=\"M0.75 9.08333L9.08333 0.75M9.08333 0.75H1.58333M9.08333 0.75V8.25\" stroke=\"white\" stroke-width=\"1.5\" stroke-linecap=\"round\" stroke-linejoin=\"round\"><\/path><\/svg>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Send Form<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>International Patients&#8217; Form<\/p>","protected":false},"author":9,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-5808","page","type-page","status-publish","hentry"],"acf":[],"_hostinger_reach_plugin_has_subscription_block":false,"_hostinger_reach_plugin_is_elementor":false,"_links":{"self":[{"href":"https:\/\/telescopecenter.com\/ar\/wp-json\/wp\/v2\/pages\/5808","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/telescopecenter.com\/ar\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/telescopecenter.com\/ar\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/telescopecenter.com\/ar\/wp-json\/wp\/v2\/users\/9"}],"replies":[{"embeddable":true,"href":"https:\/\/telescopecenter.com\/ar\/wp-json\/wp\/v2\/comments?post=5808"}],"version-history":[{"count":45,"href":"https:\/\/telescopecenter.com\/ar\/wp-json\/wp\/v2\/pages\/5808\/revisions"}],"predecessor-version":[{"id":7618,"href":"https:\/\/telescopecenter.com\/ar\/wp-json\/wp\/v2\/pages\/5808\/revisions\/7618"}],"wp:attachment":[{"href":"https:\/\/telescopecenter.com\/ar\/wp-json\/wp\/v2\/media?parent=5808"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}