{"id":147,"date":"2020-07-19T20:02:17","date_gmt":"2020-07-19T20:02:17","guid":{"rendered":"http:\/\/sailingmedicalservices.com\/?page_id=147"},"modified":"2024-08-07T04:04:36","modified_gmt":"2024-08-07T04:04:36","slug":"surrogacy-candidate","status":"publish","type":"page","link":"https:\/\/dawnermedicalservices.com\/zh\/surrogacy-candidate\/","title":{"rendered":"Surrogacy Candidate"},"content":{"rendered":"<style>\r\n\t.wpsm_tab_300 .wpsm_nav-tabs li a,\r\n\t.wpsm_tab_300 .wpsm_nav-tabs li a:hover,\r\n\t.wpsm_tab_300 .wpsm_nav-tabs li a:focus{\r\n\t\toutline: none;\r\n\t\ttext-decoration: none;\r\n\t}\r\n\t#wpsm_tab_container_300 a,\r\n\t#wpsm_tab_container_300 a:hover{\r\n\t\t-webkit-box-shadow:none;\r\n\t\tbox-shadow:none;\r\n\t}\r\n\t#wpsm_tab_container_300{\r\n\t\toverflow: hidden;\r\n\t\tdisplay: block;\r\n\t\twidth: 100%;\r\n\t\tborder: 0px solid #ddd;\r\n\t\tmargin-bottom: 30px;\r\n\t\tmargin-top:20px;\r\n\t}\r\n\t#wpsm_tab_container_300 ul{\r\n\t\tpadding:0;\r\n\t\tmargin:0;\r\n\t}\r\n\t.wpsm_tab_300 .wpsm_nav-tabs li{\r\n\t\tmargin-left:0;\r\n\t}\r\n\t.wpsm_tab_300 .wpsm_nav-tabs li a i{\r\n\t\theight:auto;\r\n\t}\r\n\t#wpsm_tab_container_300 .wpsm_nav li .wpsm_tabs_img_icon,\r\n\t#wpsm_tab_container_300 .wpsm_nav li .wpsm-icons{\r\n\t\tvertical-align:middle;\r\n\t}\r\n\t@media only screen and (max-width: 600px) {\r\n\t\t.wpsm_tab_300 .wpsm_nav-tabs li{\r\n\t\t\tfloat:none;\r\n\t\t}\r\n\t\t\r\n\t}\r\n\t\t\t@media only screen and (min-width: 601px) \r\n\t\t{\r\n\t\t\t\t\t\t\t#wpsm_tab_container_300 .wpsm_tab_300 .wpsm_nav-tabs li\r\n\t\t\t\t{\r\n\t\t\t\tfloat:left;\r\n\t\t\t\t}\r\n\t\t\t\t\t}\r\n\t\t\r\n\t\t\t#wpsm_tab_container_300 .wpsm_nav li .wpsm_tabs_img_icon{\r\n\t\tbox-shadow:none;\r\n\t\t-webkit-box-shadow:none;\r\n\t\t\t\t\twidth:21px;\r\n\t\t\theight:21px;\r\n\t\t\t}\r\n\t\r\n\t#wpsm_tab_container_300 .wpsm_tab_300 .wpsm_nav-tabs li a\r\n\t{\r\n\t\t\t\t\t\tbackground-image: none !important;\r\n\t\t\t\t}\r\n\t\r\n\t\t.wpsm_tab_300 .wpsm_nav-tabs li a i,\r\n\t.wpsm_tab_300 .wpsm_nav-tabs li a img\r\n\t{\t\r\n\t\t\t\r\n\t\t\tdisplay:inline;\r\n\t\t\tmargin:0 8px 0 0;\r\n\t\t\t\t}\r\n\t<\/style><style>\r\n\/*Design 1 *\/\r\n.wpsm_tab_300 .wpsm_nav-tabs li a,\r\n.wpsm_tab_300 a:hover,\r\n.wpsm_tab_300 a:focus{\r\n    outline: none;\r\n    text-decoration: none;\r\n}\r\n.wpsm_tab_300 .wpsm_nav-tabs{\r\n    background: transparent;\r\n\tborder-bottom:0px;\r\n}\r\n.wpsm_tab_300 .wpsm_nav-tabs li{\r\n    text-align: center;\r\n    margin-right: 0px;\r\n}\r\n.wpsm_tab_300 .wpsm_nav-tabs li a{\r\n    font-size: 21px;\r\n    color: #000000;\r\n    padding: 15px 15px;\r\n    background: #ffffff;\r\n    margin-right: 0;\r\n    border-radius: 0;\r\n    border: none;\r\n    position: relative;\r\n    transition: all 0.5s ease 0s;\r\n\tfont-weight:300;\r\n\tfont-family:Open Sans;\r\n\ttext-align:center;\r\n\tvertical-align:middle;\r\n}\r\n.wpsm_tab_300 .wpsm_nav-tabs li.active a,\r\n.wpsm_tab_300 .wpsm_nav-tabs li a:hover{\r\n    background: #ffeaea !important;\r\n    color: #ea7066 !important;\r\n    border: none;\r\n}\r\n.wpsm_tab_300 .wpsm_nav-tabs li a i{\r\n\t\/*padding-left:8px;\r\n\tpadding-right:8px;*\/\r\n\tcolor: #000000;\r\n\tfont-size: 21px;\r\n}\r\n\r\n.wpsm_tab_300 .wpsm_nav-tabs li.active a i,\r\n.wpsm_tab_300 .wpsm_nav-tabs li a:hover i{\r\n\tcolor: #ea7066 !important;\r\n}\r\n.wpsm_tab_300 .wpsm_tab_content{\r\n    font-size: 18px;\r\n    color: #000000;\r\n\tbackground: #ffffff;\r\n    padding: 25px 35px;\r\n    border: 3px solid #ea7066;\r\n\tfont-family:Open Sans;\r\n\tline-height:1.6;\r\n}\r\n.wpsm_tab_300 .wpsm_tab_content .tab-pane p{\r\n    font-size: 18px;\r\n    color: #000000;\r\n\tbackground: #ffffff;\r\n    font-family:Open Sans;\r\n\tline-height:1.6;\r\n\tpadding:0;\r\n\ttext-align:left;\r\n}\r\n.wpsm_tab_300 .wpsm_tab_content h3{\r\n    font-size: 20px;\r\n    font-weight: bold;\r\n    margin-top: 0;\r\n}\r\n\r\n@media only screen and (max-width: 600px){\r\n    .wpsm_tab_300 .wpsm_nav-tabs li{ \r\n\t\twidth: 100% !important; \r\n\t}\r\n\t\t\t.wpsm_tab_300 .wpsm_tab_content{\r\n\t\t\tborder: 1px solid #ea7066;\r\n\t\t}\r\n\t}\r\n<\/style><div id=\"wpsm_tab_container_300\">\r\n\t<div class=\"wpsm_tab_300\"  role=\"tabpanel\">\r\n\t\t\r\n\t\t<!-- wpshopmart tabs pro menu -->\r\n\t\t<ul class=\"wpsm_nav wpsm_nav-tabs\" role=\"tablist\" id=\"myTab_300\">\r\n\t\t\t                 \r\n\t\t\t\t<li role=\"presentation\" class=\"active\">\r\n\t\t\t\t\t<a href=\"#tabs_desc_300_1\" aria-controls=\"home\" role=\"tab\" data-toggle=\"tab\"  style=\"\">\r\n\t\t\t\t\t\t<i class=\"fa fa-street-view wpsm-icons\"   ><\/i>Overview\t\t\t\t\t<\/a>\r\n\t\t\t\t<\/li>\r\n\t\t\t\t                 \r\n\t\t\t\t<li role=\"presentation\" class=\"\">\r\n\t\t\t\t\t<a href=\"#tabs_desc_300_2\" aria-controls=\"home\" role=\"tab\" data-toggle=\"tab\"  style=\"\">\r\n\t\t\t\t\t\t<i class=\"fa fa-file-text wpsm-icons\"   ><\/i>Application\t\t\t\t\t<\/a>\r\n\t\t\t\t<\/li>\r\n\t\t\t\t  \r\n\t\t<\/ul>\r\n\t\t\r\n\t\t<!-- wpshopmart tabs pro Menu Content -->\r\n\t\t<div class=\"wpsm_tab_content tabs\">\r\n\t\t\t \r\n\t\t\t\t<div role=\"tabpanel\" class=\"tab-pane animated fadeIn in active\" id=\"tabs_desc_300_1\">\r\n\t\t\t\t\t<p>It is truly wonderful that you are considering helping someone realize their dream of starting a family. The staff at Dawner Medical Services are committed to making the surrogacy process as rewarding and enjoyable as possible for you. We will assist you throughout the entire process, from the initial application and matching with intended parents, through the IVF cycle, pregnancy, delivery, and beyond.<\/p>\r\n<p>We encourage you to review the following sections before initiating your application, which is expected to take 15 to 20 minutes. If you would like to learn more or have any questions, please feel free to contact us. Our surrogacy coordinator is available to answer your questions and assist you throughout the application process.<\/p>\r\n<p><b class=\"collapseomatic\" id=\"id69ee4f981a745\"  tabindex=\"0\" title=\"About Gestational Surrogacy\"    >About Gestational Surrogacy<\/b><div id=\"target-id69ee4f981a745\" class=\"collapseomatic_content\"><\/p>\r\n<p>Gestational surrogacy is an arrangement in which a woman carries and delivers a baby for someone else. The woman who carries the baby is known as the gestational surrogate or gestational carrier. The parents-to-be, referred to as the \"intended parents,\" are involved in the pregnancy, present at the birth, and become the child's parents after birth.<\/p>\r\n<p>In gestational surrogacy, the baby is not genetically related to the gestational surrogate. Typically, the egg comes from the intended mother and the sperm from the intended father, although donor eggs, donor embryos, or donor sperm may sometimes be used. In vitro fertilization (IVF) is a crucial part of this process, as eggs from one woman are used to create an embryo that is then implanted in the gestational surrogate's uterus. During IVF, fertilization occurs in a laboratory after eggs and sperm are combined. The resulting embryo or embryos are then transferred to the gestational surrogate's uterus.<\/p>\r\n<p><\/div><\/p>\r\n<p><b class=\"collapseomatic\" id=\"id69ee4f981a795\"  tabindex=\"0\" title=\"Eligibility for Surrogate Mother\"    >Eligibility for Surrogate Mother<\/b><div id=\"target-id69ee4f981a795\" class=\"collapseomatic_content\"><\/p>\r\n<ul>\r\n<li>Genuine interest and commitment<\/li>\r\n<li>Age between 20 and 38<\/li>\r\n<li>Has given birth to at least one child<\/li>\r\n<li>Maintains a healthy lifestyle<\/li>\r\n<li>Financially stable<\/li>\r\n<li>Responsible lifestyle<\/li>\r\n<li>Non-smoker<\/li>\r\n<li>BMI under 32<\/li>\r\n<li>No history of mental illness<\/li>\r\n<li>Must agree to psychological and drug screenings<\/li>\r\n<li>No IUD expected<\/li>\r\n<li>Tubal ligation is acceptable<\/li>\r\n<\/ul>\r\n<p><\/div><\/p>\r\n<p><b class=\"collapseomatic\" id=\"id69ee4f981a7a7\"  tabindex=\"0\" title=\"Your Benefits\"    >Your Benefits<\/b><div id=\"target-id69ee4f981a7a7\" class=\"collapseomatic_content\"><\/p>\r\n<ul>\r\n<li>Total compensation ranging from $35,000 to $70,000, depending on your background<\/li>\r\n<li>Fully covered travel and lodging expenses<\/li>\r\n<li>Comprehensive healthcare provided at no cost to you immediately after pregnancy occurs<\/li>\r\n<li>Extensive health tests provided free of charge prior to pregnancy to ensure your suitability for surrogacy, including cervical cultures, blood tests, a hysteroscopy, and a uterine evaluation<\/li>\r\n<li>Gifts from intended parents<\/li>\r\n<\/ul>\r\n<p><\/div><\/p>\r\n<p><b class=\"collapseomatic\" id=\"id69ee4f981a7b5\"  tabindex=\"0\" title=\"How to Apply\"    >How to Apply<\/b><div id=\"target-id69ee4f981a7b5\" class=\"collapseomatic_content\"><\/p>\r\n<p>Dawner Medical Services strives to work with women who not only meet but exceed the surrogacy requirements. We seek exceptional women who are willing to help build families through surrogacy. Our Surrogacy team will guide you through the entire journey, providing consistent, personalized support for you and the intended parents. Our primary goal is to ensure you meet the necessary qualifications while educating you about our surrogacy program and the overall process.<\/p>\r\n<p>Your first step to becoming a surrogate mother is to complete the profile questionnaire under the \"<strong>Application<\/strong>\" tab. You will receive an email notification with a unique <em>Profile Submission ID<\/em>. Please save this ID.<\/p>\r\n<p>Your application will be reviewed by our surrogate mother recruiting team and medical directors. Once your application is accepted, our staff will contact you for further information. After all necessary information has been collected, your profile will be presented to potential recipients anonymously. Once a match is finalized, our office will contact you to begin the surrogacy process.<\/p>\r\n<p><\/div><\/p>\r\n<p><b class=\"collapseomatic\" id=\"id69ee4f981a7c1\"  tabindex=\"0\" title=\"Application Inquiry\"    >Application Inquiry<\/b><div id=\"target-id69ee4f981a7c1\" class=\"collapseomatic_content\"><\/p>\r\n<p>To follow up on your submitted application, please visit the \"<a style=\"color: #ff00ff;\" href=\"https:\/\/dawnermedicalservices.com\/zh\/contact-us\/\" target=\"_blank\" rel=\"noopener\">Contact Us<\/a>\" page and submit your follow-up request online. Indicate that you are a <em>Registered Donor or Surrogate Candidate<\/em>, select \"<em>Egg Donor Candidate<\/em>\" from the Candidate Category, and enter the <em>Profile Submission ID<\/em> you received in your email notification. 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equals&quot;,&quot;if_value&quot;:&quot;Student&quot;},{&quot;if_field&quot;:&quot;working-status&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;Independent contractor&quot;},{&quot;if_field&quot;:&quot;working-status&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;&quot;},{&quot;if_field&quot;:&quot;working-status&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;Unemployed&quot;}]},{&quot;then_field&quot;:&quot;group-partner-working-status&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;marital&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Married&quot;}]},{&quot;then_field&quot;:&quot;group-partner-working-status&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;any-partner&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;},{&quot;if_field&quot;:&quot;marital&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;Married&quot;},{&quot;if_field&quot;:&quot;marital&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;&quot;}]},{&quot;then_field&quot;:&quot;group-partner-current-employment&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;partner-working-status&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;Student&quot;},{&quot;if_field&quot;:&quot;partner-working-status&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;Independent contractor&quot;},{&quot;if_field&quot;:&quot;partner-working-status&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;&quot;},{&quot;if_field&quot;:&quot;partner-working-status&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;Unemployed&quot;}]},{&quot;then_field&quot;:&quot;group-partner-current-income&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;marital&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Married&quot;}]},{&quot;then_field&quot;:&quot;group-partner-current-income&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;any-partner&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;},{&quot;if_field&quot;:&quot;marital&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;Married&quot;},{&quot;if_field&quot;:&quot;marital&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;&quot;}]},{&quot;then_field&quot;:&quot;group-smoke-history&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;smoke&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-drink-history&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;drink&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-medication&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;medication&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-medical-issue&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;any-medical-issue&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-eating-disorder&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;any-eating-disorder&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-drug-alcohol-abuse&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;drug-alcohol-abuse&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-allergy-history&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;allergy&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-chronic-problem-history&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;chronic-problem&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-infectious-disease-history&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;infectious-disease&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-surgery-history&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;surgery&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-hospitalized-history&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;hospitalized&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-postpartum-depression&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;any-postpartum-depression&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-any-psychiatric-problem&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;any-psychiatric-problem&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-psychiatric-problem-history&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;psychiatric-problem&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;&quot;},{&quot;if_field&quot;:&quot;any-psychiatric-problem&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-blood-transfusion&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;any-blood-transfusion&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-blood-donation-rejection&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;blood-donation-rejection&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-menstrual-cycle&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;menstrual-cycle&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Irregular&quot;}]},{&quot;then_field&quot;:&quot;group-last-pap-test&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;last-pap-test-date&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;&quot;}]},{&quot;then_field&quot;:&quot;group-last-pap-test-reason&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;last-pap-test-result&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;No&quot;},{&quot;if_field&quot;:&quot;last-pap-test-date&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;&quot;}]},{&quot;then_field&quot;:&quot;group-infertility-treatment&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;infertility-treatment&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Irregular&quot;}]},{&quot;then_field&quot;:&quot;group-uterine-cyst&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;uterine-cyst&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Irregular&quot;}]},{&quot;then_field&quot;:&quot;group-any-reproductive-illness&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;any-reproductive-illness&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-reproductive-illness&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;reproductive-illness&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;&quot;},{&quot;if_field&quot;:&quot;any-reproductive-illness&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-pregnant-times&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;pregnancy&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-pregnant-years&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;pregnancy&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-miscarriage&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;pregnancy&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-miscarriage-times&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;miscarriage&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;},{&quot;if_field&quot;:&quot;pregnancy&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-miscarriage-years&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;miscarriage&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;},{&quot;if_field&quot;:&quot;pregnancy&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-abortion&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;pregnancy&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-abortion-times&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;abortion&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;},{&quot;if_field&quot;:&quot;pregnancy&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-abortion-years&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;abortion&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;},{&quot;if_field&quot;:&quot;pregnancy&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-stillbirth&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;pregnancy&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-stillbirth-times&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;stillbirth&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;},{&quot;if_field&quot;:&quot;pregnancy&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-stillbirth-years&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;stillbirth&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;},{&quot;if_field&quot;:&quot;pregnancy&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-delivery&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;pregnancy&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-delivery-times&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;delivery&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;},{&quot;if_field&quot;:&quot;pregnancy&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-delivery-years&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;delivery&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;},{&quot;if_field&quot;:&quot;pregnancy&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-delivery-children&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;delivery&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;},{&quot;if_field&quot;:&quot;pregnancy&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-delivery-defect&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;delivery&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;},{&quot;if_field&quot;:&quot;pregnancy&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-delivery-defect-details&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;delivery-defect&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;},{&quot;if_field&quot;:&quot;delivery&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;},{&quot;if_field&quot;:&quot;pregnancy&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-sexually-active&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;sexually-active&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-std-partner&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;std-partner&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-birth-control&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;birth-control&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-any-contraception&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;any-contraception&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-contraception&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;contraception&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;IUD&quot;},{&quot;if_field&quot;:&quot;any-contraception&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-contraception&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;contraception&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Other&quot;},{&quot;if_field&quot;:&quot;any-contraception&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-why-gc&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;why-gc&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Other&quot;}]},{&quot;then_field&quot;:&quot;group-family-know-decision&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;family-know-decision&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-no-abortion&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;no-abortion&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-not-gc&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;not-gc&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-children&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;any-children&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-children-death&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;any-children&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-children-death-details&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;any-children&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;},{&quot;if_field&quot;:&quot;any-dead-children&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-children-defect&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;any-children&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-children-defect-details&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;any-children&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;},{&quot;if_field&quot;:&quot;any-defective-children&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-sibling&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;sibling-number&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;0&quot;},{&quot;if_field&quot;:&quot;sibling-number&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;&quot;}]},{&quot;then_field&quot;:&quot;group-sibling-health-issue&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;sibling-health-issue&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-mother-health-issue&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mother-health-issue&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-father-health-issue&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;father-health-issue&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-exercise&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;exercise&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;&quot;},{&quot;if_field&quot;:&quot;exercise&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;Never&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false}}\" \/>\n<input type=\"hidden\" name=\"upload_dir\" value=\"1559259502\" \/>\n<input type=\"hidden\" name=\"generate_name\" value=\"04-26-26-69ee4f981d8b4\" \/>\n<\/div>\n<p>\t\t<div id=\"cf7md-form\" class=\"cf7md-form\">\n\t\t\t<div class=\"mdc-layout-grid\">\n\t\t\t\t<div class=\"mdc-layout-grid__inner\">\n\t\t\t\t\t\t\t\t\t\t\n<input type=\"hidden\" name=\"status\" value=\"Available\" class=\"wpcf7-form-control wpcf7-hidden\" \/>\n<p>  <span class=\"wpcf7-form-control-wrap submission-id\"><input type=\"hidden\" name=\"submission-id\" value=\"559604090\" size=\"40\" class=\"wpcf7-form-control wpcf7dtx-dynamictext wpcf7-dynamichidden\" aria-invalid=\"false\" \/><\/span><br \/>\n  \t\t\t<div class=\"cf7md-item cf7md-card mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t\t<div class=\"mdc-card\">\n\t\t\t\t\t\t\t\t\t\t\t<section class=\"cf7md-card-header\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<h3 class=\"cf7md-card-title cf7md-card-title--\">Personal Information<\/h3>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<p class=\"cf7md-card-subtitle\">Tell us about yourself<\/p>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/section>\n\t\t\t\t\t\t\t\t\t\t<section class=\"cf7md-card-body\">\n\t\t\t\t\t\t<div class=\"mdc-layout-grid__inner\">\n\t\t\t\t\t\t\t\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"firstname\"><input type=\"text\" name=\"firstname\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">First name<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"lastname\"><input type=\"text\" name=\"lastname\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Last name<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-9-desktop mdc-layout-grid__cell--span-6-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"nickname\"><input type=\"text\" name=\"nickname\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Preferred nickname<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"citizenship\"><select name=\"citizenship\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"United States\">United States<\/option><option value=\"Afghanistan\">Afghanistan<\/option><option value=\"Albania\">Albania<\/option><option value=\"Algeria\">Algeria<\/option><option value=\"Andorra\">Andorra<\/option><option value=\"Angola\">Angola<\/option><option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option><option value=\"Argentina\">Argentina<\/option><option value=\"Armenia\">Armenia<\/option><option value=\"Australia\">Australia<\/option><option value=\"Austria\">Austria<\/option><option value=\"Azerbaijan\">Azerbaijan<\/option><option value=\"Bahamas\">Bahamas<\/option><option value=\"Bahrain\">Bahrain<\/option><option value=\"Bangladesh\">Bangladesh<\/option><option value=\"Barbados\">Barbados<\/option><option value=\"Belarus\">Belarus<\/option><option value=\"Belgium\">Belgium<\/option><option value=\"Belize\">Belize<\/option><option value=\"Benin\">Benin<\/option><option value=\"Bhutan\">Bhutan<\/option><option value=\"Bolivia, Plurinational State of\">Bolivia, Plurinational State of<\/option><option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option value=\"Botswana\">Botswana<\/option><option value=\"Brazil\">Brazil<\/option><option value=\"Brunei Darussalam\">Brunei Darussalam<\/option><option value=\"Bulgaria\">Bulgaria<\/option><option value=\"Burkina Faso\">Burkina Faso<\/option><option value=\"Burundi\">Burundi<\/option><option value=\"Cambodia\">Cambodia<\/option><option value=\"Cameroon\">Cameroon<\/option><option value=\"Canada\">Canada<\/option><option value=\"Cabo Verde\">Cabo Verde<\/option><option value=\"Central African Republic\">Central African Republic<\/option><option value=\"Chad\">Chad<\/option><option value=\"Chile\">Chile<\/option><option value=\"China\">China<\/option><option value=\"Colombia\">Colombia<\/option><option value=\"Comoros\">Comoros<\/option><option value=\"Congo\">Congo<\/option><option value=\"Congo, the Democratic Republic of the\">Congo, the Democratic Republic of the<\/option><option value=\"Costa Rica\">Costa Rica<\/option><option value=\"C\u00f4te d&#039;Ivoire\">C\u00f4te d&#039;Ivoire<\/option><option value=\"Croatia\">Croatia<\/option><option value=\"Cuba\">Cuba<\/option><option value=\"Cyprus\">Cyprus<\/option><option value=\"Czech Republic\">Czech Republic<\/option><option value=\"Denmark\">Denmark<\/option><option value=\"Djibouti\">Djibouti<\/option><option value=\"Dominica\">Dominica<\/option><option value=\"Dominican Republic\">Dominican Republic<\/option><option value=\"Ecuador\">Ecuador<\/option><option value=\"Egypt\">Egypt<\/option><option value=\"El Salvador\">El Salvador<\/option><option value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option value=\"Eritrea\">Eritrea<\/option><option value=\"Estonia\">Estonia<\/option><option value=\"Ethiopia\">Ethiopia<\/option><option value=\"Fiji\">Fiji<\/option><option value=\"Finland\">Finland<\/option><option value=\"France\">France<\/option><option value=\"Gabon\">Gabon<\/option><option value=\"Gambia\">Gambia<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Germany\">Germany<\/option><option value=\"Ghana\">Ghana<\/option><option value=\"Greece\">Greece<\/option><option value=\"Grenada\">Grenada<\/option><option value=\"Guatemala\">Guatemala<\/option><option value=\"Guinea\">Guinea<\/option><option value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option value=\"Guyana\">Guyana<\/option><option value=\"Haiti\">Haiti<\/option><option value=\"Holy See (Vatican City State)\">Holy See (Vatican City State)<\/option><option value=\"Honduras\">Honduras<\/option><option value=\"Hungary\">Hungary<\/option><option value=\"Iceland\">Iceland<\/option><option value=\"India\">India<\/option><option value=\"Indonesia\">Indonesia<\/option><option value=\"Iran, Islamic Republic of\">Iran, Islamic Republic of<\/option><option value=\"Iraq\">Iraq<\/option><option value=\"Ireland\">Ireland<\/option><option value=\"Israel\">Israel<\/option><option value=\"Italy\">Italy<\/option><option value=\"Jamaica\">Jamaica<\/option><option value=\"Japan\">Japan<\/option><option value=\"Jordan\">Jordan<\/option><option value=\"Kazakhstan\">Kazakhstan<\/option><option value=\"Kenya\">Kenya<\/option><option value=\"Kiribati\">Kiribati<\/option><option value=\"Korea, Republic of\">Korea, Republic of<\/option><option value=\"Kuwait\">Kuwait<\/option><option value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option value=\"Lao People&#039;s Democratic Republic\">Lao People&#039;s Democratic Republic<\/option><option value=\"Latvia\">Latvia<\/option><option value=\"Lebanon\">Lebanon<\/option><option value=\"Lesotho\">Lesotho<\/option><option value=\"Liberia\">Liberia<\/option><option value=\"Libya\">Libya<\/option><option value=\"Liechtenstein\">Liechtenstein<\/option><option value=\"Lithuania\">Lithuania<\/option><option value=\"Luxembourg\">Luxembourg<\/option><option value=\"Macedonia, The Former Yugoslav Republic of\">Macedonia, The Former Yugoslav Republic of<\/option><option value=\"Madagascar\">Madagascar<\/option><option value=\"Malawi\">Malawi<\/option><option value=\"Malaysia\">Malaysia<\/option><option value=\"Maldives\">Maldives<\/option><option value=\"Mali\">Mali<\/option><option value=\"Malta\">Malta<\/option><option value=\"Marshall Islands\">Marshall Islands<\/option><option value=\"Mauritania\">Mauritania<\/option><option value=\"Mauritius\">Mauritius<\/option><option value=\"Mexico\">Mexico<\/option><option value=\"Micronesia, Federated States of\">Micronesia, Federated States of<\/option><option value=\"Moldova, Republic of\">Moldova, Republic of<\/option><option value=\"Monaco\">Monaco<\/option><option value=\"Mongolia\">Mongolia<\/option><option value=\"Montenegro\">Montenegro<\/option><option value=\"Morocco\">Morocco<\/option><option value=\"Mozambique\">Mozambique<\/option><option value=\"Myanmar\">Myanmar<\/option><option value=\"Namibia\">Namibia<\/option><option value=\"Nauru\">Nauru<\/option><option value=\"Nepal\">Nepal<\/option><option value=\"Netherlands\">Netherlands<\/option><option value=\"New Zealand\">New Zealand<\/option><option value=\"Nicaragua\">Nicaragua<\/option><option value=\"Niger\">Niger<\/option><option value=\"Nigeria\">Nigeria<\/option><option value=\"Norway\">Norway<\/option><option value=\"Oman\">Oman<\/option><option value=\"Pakistan\">Pakistan<\/option><option value=\"Palau\">Palau<\/option><option value=\"Palestine, State of\">Palestine, State of<\/option><option value=\"Panama\">Panama<\/option><option value=\"Papua New Guinea\">Papua New Guinea<\/option><option value=\"Paraguay\">Paraguay<\/option><option value=\"Peru\">Peru<\/option><option value=\"Philippines\">Philippines<\/option><option value=\"Poland\">Poland<\/option><option value=\"Portugal\">Portugal<\/option><option value=\"Qatar\">Qatar<\/option><option value=\"Romania\">Romania<\/option><option value=\"Russian Federation\">Russian Federation<\/option><option value=\"Rwanda\">Rwanda<\/option><option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\">Saint Lucia<\/option><option value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option><option value=\"Samoa\">Samoa<\/option><option value=\"San Marino\">San Marino<\/option><option value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option><option value=\"Saudi Arabia\">Saudi Arabia<\/option><option value=\"Senegal\">Senegal<\/option><option value=\"Serbia\">Serbia<\/option><option value=\"Seychelles\">Seychelles<\/option><option value=\"Sierra Leone\">Sierra Leone<\/option><option value=\"Singapore\">Singapore<\/option><option value=\"Slovakia\">Slovakia<\/option><option value=\"Slovenia\">Slovenia<\/option><option value=\"Solomon Islands\">Solomon Islands<\/option><option value=\"Somalia\">Somalia<\/option><option value=\"South Africa\">South Africa<\/option><option value=\"South Sudan\">South Sudan<\/option><option value=\"Spain\">Spain<\/option><option value=\"Sri Lanka\">Sri Lanka<\/option><option value=\"Sudan\">Sudan<\/option><option value=\"Suriname\">Suriname<\/option><option value=\"Swaziland\">Swaziland<\/option><option value=\"Sweden\">Sweden<\/option><option value=\"Switzerland\">Switzerland<\/option><option value=\"Syrian Arab Republic\">Syrian Arab Republic<\/option><option value=\"Taiwan, Republic of China\">Taiwan, Republic of China<\/option><option value=\"Tajikistan\">Tajikistan<\/option><option value=\"Tanzania, United Republic of\">Tanzania, United Republic of<\/option><option value=\"Thailand\">Thailand<\/option><option value=\"Timor-Leste\">Timor-Leste<\/option><option value=\"Togo\">Togo<\/option><option value=\"Tonga\">Tonga<\/option><option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option value=\"Tunisia\">Tunisia<\/option><option value=\"Turkey\">Turkey<\/option><option value=\"Turkmenistan\">Turkmenistan<\/option><option value=\"Tuvalu\">Tuvalu<\/option><option value=\"Uganda\">Uganda<\/option><option value=\"Ukraine\">Ukraine<\/option><option value=\"United Arab Emirates\">United Arab Emirates<\/option><option value=\"United Kingdom\">United Kingdom<\/option><option value=\"Uruguay\">Uruguay<\/option><option value=\"Uzbekistan\">Uzbekistan<\/option><option value=\"Vanuatu\">Vanuatu<\/option><option value=\"Venezuela, Bolivarian Republic of\">Venezuela, Bolivarian Republic of<\/option><option value=\"Viet Nam\">Viet Nam<\/option><option value=\"Western Sahara\">Western Sahara<\/option><option value=\"Yemen\">Yemen<\/option><option value=\"Zambia\">Zambia<\/option><option value=\"Zimbabwe\">Zimbabwe<\/option><\/select><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">flag<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Country of Citizenship<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"birth-country\"><select name=\"birth-country\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"United States\">United States<\/option><option value=\"Afghanistan\">Afghanistan<\/option><option value=\"Albania\">Albania<\/option><option value=\"Algeria\">Algeria<\/option><option value=\"Andorra\">Andorra<\/option><option value=\"Angola\">Angola<\/option><option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option><option value=\"Argentina\">Argentina<\/option><option value=\"Armenia\">Armenia<\/option><option value=\"Australia\">Australia<\/option><option value=\"Austria\">Austria<\/option><option value=\"Azerbaijan\">Azerbaijan<\/option><option value=\"Bahamas\">Bahamas<\/option><option value=\"Bahrain\">Bahrain<\/option><option value=\"Bangladesh\">Bangladesh<\/option><option value=\"Barbados\">Barbados<\/option><option value=\"Belarus\">Belarus<\/option><option value=\"Belgium\">Belgium<\/option><option value=\"Belize\">Belize<\/option><option value=\"Benin\">Benin<\/option><option value=\"Bhutan\">Bhutan<\/option><option value=\"Bolivia, Plurinational State of\">Bolivia, Plurinational State of<\/option><option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option value=\"Botswana\">Botswana<\/option><option value=\"Brazil\">Brazil<\/option><option value=\"Brunei Darussalam\">Brunei Darussalam<\/option><option value=\"Bulgaria\">Bulgaria<\/option><option value=\"Burkina Faso\">Burkina Faso<\/option><option value=\"Burundi\">Burundi<\/option><option value=\"Cambodia\">Cambodia<\/option><option value=\"Cameroon\">Cameroon<\/option><option value=\"Canada\">Canada<\/option><option value=\"Cabo Verde\">Cabo Verde<\/option><option value=\"Central African Republic\">Central African Republic<\/option><option value=\"Chad\">Chad<\/option><option value=\"Chile\">Chile<\/option><option value=\"China\">China<\/option><option value=\"Colombia\">Colombia<\/option><option value=\"Comoros\">Comoros<\/option><option value=\"Congo\">Congo<\/option><option value=\"Congo, the Democratic Republic of the\">Congo, the Democratic Republic of the<\/option><option value=\"Costa Rica\">Costa Rica<\/option><option value=\"C\u00f4te d&#039;Ivoire\">C\u00f4te d&#039;Ivoire<\/option><option value=\"Croatia\">Croatia<\/option><option value=\"Cuba\">Cuba<\/option><option value=\"Cyprus\">Cyprus<\/option><option value=\"Czech Republic\">Czech Republic<\/option><option value=\"Denmark\">Denmark<\/option><option value=\"Djibouti\">Djibouti<\/option><option value=\"Dominica\">Dominica<\/option><option value=\"Dominican Republic\">Dominican Republic<\/option><option value=\"Ecuador\">Ecuador<\/option><option value=\"Egypt\">Egypt<\/option><option value=\"El Salvador\">El Salvador<\/option><option value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option value=\"Eritrea\">Eritrea<\/option><option value=\"Estonia\">Estonia<\/option><option value=\"Ethiopia\">Ethiopia<\/option><option value=\"Fiji\">Fiji<\/option><option value=\"Finland\">Finland<\/option><option value=\"France\">France<\/option><option value=\"Gabon\">Gabon<\/option><option value=\"Gambia\">Gambia<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Germany\">Germany<\/option><option value=\"Ghana\">Ghana<\/option><option value=\"Greece\">Greece<\/option><option value=\"Grenada\">Grenada<\/option><option value=\"Guatemala\">Guatemala<\/option><option value=\"Guinea\">Guinea<\/option><option value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option value=\"Guyana\">Guyana<\/option><option value=\"Haiti\">Haiti<\/option><option value=\"Holy See (Vatican City State)\">Holy See (Vatican City State)<\/option><option value=\"Honduras\">Honduras<\/option><option value=\"Hungary\">Hungary<\/option><option value=\"Iceland\">Iceland<\/option><option value=\"India\">India<\/option><option value=\"Indonesia\">Indonesia<\/option><option value=\"Iran, Islamic Republic of\">Iran, Islamic Republic of<\/option><option value=\"Iraq\">Iraq<\/option><option value=\"Ireland\">Ireland<\/option><option value=\"Israel\">Israel<\/option><option value=\"Italy\">Italy<\/option><option value=\"Jamaica\">Jamaica<\/option><option value=\"Japan\">Japan<\/option><option value=\"Jordan\">Jordan<\/option><option value=\"Kazakhstan\">Kazakhstan<\/option><option value=\"Kenya\">Kenya<\/option><option value=\"Kiribati\">Kiribati<\/option><option value=\"Korea, Republic of\">Korea, Republic of<\/option><option value=\"Kuwait\">Kuwait<\/option><option value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option value=\"Lao People&#039;s Democratic Republic\">Lao People&#039;s Democratic Republic<\/option><option value=\"Latvia\">Latvia<\/option><option value=\"Lebanon\">Lebanon<\/option><option value=\"Lesotho\">Lesotho<\/option><option value=\"Liberia\">Liberia<\/option><option value=\"Libya\">Libya<\/option><option value=\"Liechtenstein\">Liechtenstein<\/option><option value=\"Lithuania\">Lithuania<\/option><option value=\"Luxembourg\">Luxembourg<\/option><option value=\"Macedonia, The Former Yugoslav Republic of\">Macedonia, The Former Yugoslav Republic of<\/option><option value=\"Madagascar\">Madagascar<\/option><option value=\"Malawi\">Malawi<\/option><option value=\"Malaysia\">Malaysia<\/option><option value=\"Maldives\">Maldives<\/option><option value=\"Mali\">Mali<\/option><option value=\"Malta\">Malta<\/option><option value=\"Marshall Islands\">Marshall Islands<\/option><option value=\"Mauritania\">Mauritania<\/option><option value=\"Mauritius\">Mauritius<\/option><option value=\"Mexico\">Mexico<\/option><option value=\"Micronesia, Federated States of\">Micronesia, Federated States of<\/option><option value=\"Moldova, Republic of\">Moldova, Republic of<\/option><option value=\"Monaco\">Monaco<\/option><option value=\"Mongolia\">Mongolia<\/option><option value=\"Montenegro\">Montenegro<\/option><option value=\"Morocco\">Morocco<\/option><option value=\"Mozambique\">Mozambique<\/option><option value=\"Myanmar\">Myanmar<\/option><option value=\"Namibia\">Namibia<\/option><option value=\"Nauru\">Nauru<\/option><option value=\"Nepal\">Nepal<\/option><option value=\"Netherlands\">Netherlands<\/option><option value=\"New Zealand\">New Zealand<\/option><option value=\"Nicaragua\">Nicaragua<\/option><option value=\"Niger\">Niger<\/option><option value=\"Nigeria\">Nigeria<\/option><option value=\"Norway\">Norway<\/option><option value=\"Oman\">Oman<\/option><option value=\"Pakistan\">Pakistan<\/option><option value=\"Palau\">Palau<\/option><option value=\"Palestine, State of\">Palestine, State of<\/option><option value=\"Panama\">Panama<\/option><option value=\"Papua New Guinea\">Papua New Guinea<\/option><option value=\"Paraguay\">Paraguay<\/option><option value=\"Peru\">Peru<\/option><option value=\"Philippines\">Philippines<\/option><option value=\"Poland\">Poland<\/option><option value=\"Portugal\">Portugal<\/option><option value=\"Qatar\">Qatar<\/option><option value=\"Romania\">Romania<\/option><option value=\"Russian Federation\">Russian Federation<\/option><option value=\"Rwanda\">Rwanda<\/option><option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\">Saint Lucia<\/option><option value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option><option value=\"Samoa\">Samoa<\/option><option value=\"San Marino\">San Marino<\/option><option value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option><option value=\"Saudi Arabia\">Saudi Arabia<\/option><option value=\"Senegal\">Senegal<\/option><option value=\"Serbia\">Serbia<\/option><option value=\"Seychelles\">Seychelles<\/option><option value=\"Sierra Leone\">Sierra Leone<\/option><option value=\"Singapore\">Singapore<\/option><option value=\"Slovakia\">Slovakia<\/option><option value=\"Slovenia\">Slovenia<\/option><option value=\"Solomon Islands\">Solomon Islands<\/option><option value=\"Somalia\">Somalia<\/option><option value=\"South Africa\">South Africa<\/option><option value=\"South Sudan\">South Sudan<\/option><option value=\"Spain\">Spain<\/option><option value=\"Sri Lanka\">Sri Lanka<\/option><option value=\"Sudan\">Sudan<\/option><option value=\"Suriname\">Suriname<\/option><option value=\"Swaziland\">Swaziland<\/option><option value=\"Sweden\">Sweden<\/option><option value=\"Switzerland\">Switzerland<\/option><option value=\"Syrian Arab Republic\">Syrian Arab Republic<\/option><option value=\"Taiwan, Republic of China\">Taiwan, Republic of China<\/option><option value=\"Tajikistan\">Tajikistan<\/option><option value=\"Tanzania, United Republic of\">Tanzania, United Republic of<\/option><option value=\"Thailand\">Thailand<\/option><option value=\"Timor-Leste\">Timor-Leste<\/option><option value=\"Togo\">Togo<\/option><option value=\"Tonga\">Tonga<\/option><option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option value=\"Tunisia\">Tunisia<\/option><option value=\"Turkey\">Turkey<\/option><option value=\"Turkmenistan\">Turkmenistan<\/option><option value=\"Tuvalu\">Tuvalu<\/option><option value=\"Uganda\">Uganda<\/option><option value=\"Ukraine\">Ukraine<\/option><option value=\"United Arab Emirates\">United Arab Emirates<\/option><option value=\"United Kingdom\">United Kingdom<\/option><option value=\"Uruguay\">Uruguay<\/option><option value=\"Uzbekistan\">Uzbekistan<\/option><option value=\"Vanuatu\">Vanuatu<\/option><option value=\"Venezuela, Bolivarian Republic of\">Venezuela, Bolivarian Republic of<\/option><option value=\"Viet Nam\">Viet Nam<\/option><option value=\"Western Sahara\">Western Sahara<\/option><option value=\"Yemen\">Yemen<\/option><option value=\"Zambia\">Zambia<\/option><option value=\"Zimbabwe\">Zimbabwe<\/option><\/select><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">flag<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Country of Birth<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><input type=\"text\" name=\"address\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">place<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Street address<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"city\"><input type=\"text\" name=\"city\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">place<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">City<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"state\"><input type=\"text\" name=\"state\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">place<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">State\/Country<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"birthdate\"><input type=\"date\" name=\"birthdate\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">event<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Birth date<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input type=\"email\" name=\"email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">email<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Email<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"phone\"><input type=\"tel\" name=\"phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">phone<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Phone<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"secondary-phone\"><input type=\"tel\" name=\"secondary-phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">phone<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Secondary phone<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"bestway\"><select name=\"bestway\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"Both\" selected=\"selected\">Both<\/option><option value=\"Email\">Email<\/option><option value=\"Phone\">Phone<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Best way to reach you<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"besttime\"><select name=\"besttime\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"Any Time\" selected=\"selected\">Any Time<\/option><option value=\"Morning\">Morning<\/option><option value=\"Afternoon\">Afternoon<\/option><option value=\"Evening\">Evening<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Best time to call you<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<p>    \t\t<div class=\"cf7md-item mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t\n    <label><br \/>\n<h4>Upload your photos* (Please follow <a href=\"\" style=\"color:#FF00FF;\" class=\"spu-open-354\">Photo Guidelines<\/a>)<\/h4>\n<p>      <span class=\"wpcf7-form-control-wrap photos\"><input type=\"file\" name=\"photos\" size=\"40\" class=\"wpcf7-form-control wpcf7-drag-n-drop-file d-none\" aria-required=\"true\" aria-invalid=\"false\" multiple=\"multiple\" data-name=\"photos\" data-type=\"jpg|jpeg|png|tiff|gif\" data-limit=\"5242880\" data-max=\"10\" data-id=\"127\" accept=\".jpg, .jpeg, .png, .tiff, .gif\" \/><\/span><br \/>\n    <\/label><br \/>\n    \t\t<\/div>\n\t\t\t\t<div class=\"cf7md-item mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t\n    <label><br \/>\n<h4>Upload your video (Please follow <a href=\"\" style=\"color:#FF00FF;\" class=\"spu-open-355\">Video Guidelines<\/a>)<\/h4>\n<p>      <span class=\"wpcf7-form-control-wrap video\"><input type=\"file\" name=\"video\" size=\"40\" class=\"wpcf7-form-control wpcf7-drag-n-drop-file d-none\" aria-invalid=\"false\" multiple=\"multiple\" data-name=\"video\" data-type=\"mp4|avi|mov|flv|wmv\" data-limit=\"31457280\" data-max=\"1\" data-id=\"127\" accept=\".mp4, .avi, .mov, .flv, .wmv\" \/><\/span><br \/>\n    <\/label><br \/>\n    \t\t<\/div>\n\t\t<\/p>\n<p>    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-contact-name\"><input type=\"text\" name=\"emergency-contact-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Emergency contact name<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-contact-phone\"><input type=\"tel\" name=\"emergency-contact-phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">phone<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Emergency contact phone<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"us-citizen-perm-resident\"><select name=\"us-citizen-perm-resident\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Are you a US citizen or permanent resident?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<div data-id=\"group-foreigner\" data-orig_data_id=\"group-foreigner\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"foreigner\"><input type=\"text\" name=\"foreigner\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n       \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate your citizenship and US visa type<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"reference-source\"><select name=\"reference-source\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Search engine (Google, Bing, Baidu, etc.)\">Search engine (Google, Bing, Baidu, etc.)<\/option><option value=\"Referred by someone\">Referred by someone<\/option><option value=\"Web Ads\">Web Ads<\/option><option value=\"Social media\">Social media<\/option><option value=\"Newspaper\">Newspaper<\/option><option value=\"Forum or Blog\">Forum or Blog<\/option><option value=\"Other\">Other<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How did you hear about us?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-reference-source\" data-orig_data_id=\"group-reference-source\"  data-class=\"wpcf7cf_group\">\n      \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"reference-source-name\"><input type=\"text\" name=\"reference-source-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n      \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">label<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate the name of source<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<p>  \t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<\/p>\n\t\t\t<div class=\"cf7md-item cf7md-card mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t\t<div class=\"mdc-card\">\n\t\t\t\t\t\t\t\t\t\t\t<section class=\"cf7md-card-header\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<h3 class=\"cf7md-card-title cf7md-card-title--\">General Information<\/h3>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<p class=\"cf7md-card-subtitle\">Tell us more about yourself<\/p>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/section>\n\t\t\t\t\t\t\t\t\t\t<section class=\"cf7md-card-body\">\n\t\t\t\t\t\t<div class=\"mdc-layout-grid__inner\">\n\t\t\t\t\t\t\t\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"race\"><select name=\"race\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"American Indian or Alaska Native\">American Indian or Alaska Native<\/option><option value=\"Asian\">Asian<\/option><option value=\"Black or African American\">Black or African American<\/option><option value=\"Hispanic or Latino\">Hispanic or Latino<\/option><option value=\"Native Hawaiian or Other Pacific Islander\">Native Hawaiian or Other Pacific Islander<\/option><option value=\"White\">White<\/option><option value=\"Other\">Other<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Ethnicity (Select Other for mixed-ethnicity)<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<div data-id=\"group-mixed-race\" data-orig_data_id=\"group-mixed-race\"  data-class=\"wpcf7cf_group\">\n      \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"primary-race\"><select name=\"primary-race\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"American Indian or Alaska Native\">American Indian or Alaska Native<\/option><option value=\"Asian\">Asian<\/option><option value=\"Black or African American\">Black or African American<\/option><option value=\"Hispanic or Latino\">Hispanic or Latino<\/option><option value=\"Native Hawaiian or Other Pacific Islander\">Native Hawaiian or Other Pacific Islander<\/option><option value=\"White\">White<\/option><\/select><\/span><br \/>\n      \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Primary ethnicity<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-mixed-race\" data-orig_data_id=\"group-mixed-race\"  data-class=\"wpcf7cf_group\">\n      \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"secondary-race\"><select name=\"secondary-race\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"American Indian or Alaska Native\">American Indian or Alaska Native<\/option><option value=\"Asian\">Asian<\/option><option value=\"Black or African American\">Black or African American<\/option><option value=\"Hispanic or Latino\">Hispanic or Latino<\/option><option value=\"Native Hawaiian or Other Pacific Islander\">Native Hawaiian or Other Pacific Islander<\/option><option value=\"White\">White<\/option><\/select><\/span><br \/>\n      \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Secondary ethnicity<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"religion\"><select name=\"religion\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"None\">None<\/option><option value=\"Buddhism\">Buddhism<\/option><option value=\"Christianity\">Christianity<\/option><option value=\"Folk religions\">Folk religions<\/option><option value=\"Hinduism\">Hinduism<\/option><option value=\"Islam\">Islam<\/option><option value=\"Judaism\">Judaism<\/option><option value=\"Other\">Other<\/option><option value=\"I&#039;d rather not say\">I&#039;d rather not say<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Religion<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n       <span class=\"wpcf7-form-control-wrap\" data-name=\"marital\"><select name=\"marital\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Single\">Single<\/option><option value=\"Married\">Married<\/option><option value=\"Separated\">Separated<\/option><option value=\"Divorced\">Divorced<\/option><option value=\"Widowed\">Widowed<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Marital status<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-spouse\" data-orig_data_id=\"group-spouse\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"spouse-name\"><input type=\"text\" name=\"spouse-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Spouse's name<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-spouse\" data-orig_data_id=\"group-spouse\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"spouse-phone\"><input type=\"tel\" name=\"spouse-phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">phone<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Spouse's contact phone<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-marriage-years\" data-orig_data_id=\"group-marriage-years\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"marriage-years\"><input type=\"number\" name=\"marriage-years\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How many years have you been married?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-any-marriage-issue\" data-orig_data_id=\"group-any-marriage-issue\"  data-class=\"wpcf7cf_group\">\n       \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"any-marriage-issue\"><select name=\"any-marriage-issue\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n       \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever experienced any marital problems?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-marriage-issue\" data-orig_data_id=\"group-marriage-issue\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t<br \/>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"marriage-issue\"><textarea name=\"marriage-issue\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span><br \/>\n       \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate your marital problems (Confidentiality will be honored)<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-separated-months\" data-orig_data_id=\"group-separated-months\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"separated-months\"><input type=\"number\" name=\"separated-months\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How many months have you separated from your (ex-)spouse?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-separated-reason\" data-orig_data_id=\"group-separated-reason\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"separated-reason\"><textarea name=\"separated-reason\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate cause of breakup<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-any-partner\" data-orig_data_id=\"group-any-partner\"  data-class=\"wpcf7cf_group\">\n       \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"any-partner\"><select name=\"any-partner\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n       \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Are you living with any partner?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-partner\" data-orig_data_id=\"group-partner\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"partner-months\"><input type=\"number\" name=\"partner-months\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How many months have you been living with your partner?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<p>    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-2-desktop mdc-layout-grid__cell--span-2-tablet mdc-layout-grid__cell--span-2-phone\">\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"height-foot\"><input type=\"number\" name=\"height-foot\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Height(ft)<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-3-desktop mdc-layout-grid__cell--span-2-tablet mdc-layout-grid__cell--span-2-phone\">\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"height-inch\"><input type=\"number\" name=\"height-inch\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Height(in)<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"weight\"><input type=\"number\" name=\"weight\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Weight (lb)<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<p>    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-4-desktop mdc-layout-grid__cell--span-3-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"blood\"><select name=\"blood\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"A\">A<\/option><option value=\"B\">B<\/option><option value=\"AB\">AB<\/option><option value=\"O\">O<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Blood type<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-4-desktop mdc-layout-grid__cell--span-3-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"blood-rh\"><select name=\"blood-rh\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Positive\">Positive<\/option><option value=\"Negative\">Negative<\/option><option value=\"Unknown\">Unknown<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Blood RH factor<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-4-desktop mdc-layout-grid__cell--span-3-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"shape\"><select name=\"shape\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Slender\">Slender<\/option><option value=\"Athletic\">Athletic<\/option><option value=\"Chubby\">Chubby<\/option><option value=\"Average\">Average<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Body shape<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"any-conviction\"><select name=\"any-conviction\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Did you or your current spouse\/partner have any conviction of misdemeanor or felony?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-conviction\" data-orig_data_id=\"group-conviction\"  data-class=\"wpcf7cf_group\">\n      \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"conviction-details\"><textarea name=\"conviction-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please further describe<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"any-bad-experience\"><select name=\"any-bad-experience\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you or your immediate family experienced serious accident or severe crime?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-bad-experience\" data-orig_data_id=\"group-bad-experience\"  data-class=\"wpcf7cf_group\">\n      \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"bad-experience-details\"><textarea name=\"bad-experience-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please further describe<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<p>    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"des-medication\"><select name=\"des-medication\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Unknown\">Unknown<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Did your mother take DES medication while pregnant with you?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"tattoo\"><select name=\"tattoo\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you gotten a tattoo or any body piercing in the last 18 months?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"any-child-adopted\"><select name=\"any-child-adopted\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever placed a child up for adoption?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<div data-id=\"group-child-adopted\" data-orig_data_id=\"group-child-adopted\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"child-adopted-details\"><textarea name=\"child-adopted-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please describe your experience<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"any-foster-child\"><select name=\"any-foster-child\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever cared for a foster child?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-foster-child\" data-orig_data_id=\"group-foster-child\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"foster-child-details\"><textarea name=\"foster-child-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please describe your experience<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"had-genetic-disease\"><select name=\"had-genetic-disease\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Unknown\">Unknown<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">local_hospital<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Any genetic disease in your family?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-genetic-disease-history\" data-orig_data_id=\"group-genetic-disease-history\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"past-genetic-diseases\"><input type=\"text\" name=\"past-genetic-diseases\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">local_hospital<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Known genetic diseases<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<p>    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"have-driver-license\"><select name=\"have-driver-license\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Do you have a valid driver's license?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"have-gun\"><select name=\"have-gun\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Do you have gun weapon in your home?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"have-car\"><select name=\"have-car\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Do you have a car?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<div data-id=\"group-car\" data-orig_data_id=\"group-car\"  data-class=\"wpcf7cf_group\">\n      \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"car-insured\"><select name=\"car-insured\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Is your car insured?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-public-transportation\" data-orig_data_id=\"group-public-transportation\"  data-class=\"wpcf7cf_group\">\n      \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"access-public-transport\"><select name=\"access-public-transport\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Do you have access to public transportation?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"insured\"><select name=\"insured\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Do you have health insurance?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-insurance-provider\" data-orig_data_id=\"group-insurance-provider\"  data-class=\"wpcf7cf_group\">\n      \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"insurance-provider\"><input type=\"text\" name=\"insurance-provider\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">local_hospital<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Name of health insurance provider<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"was-surrogate\"><select name=\"was-surrogate\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you been a gestational carrier before?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-surrogate-history\" data-orig_data_id=\"group-surrogate-history\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"past-surrogations\"><input type=\"number\" name=\"past-surrogations\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How many gestational carryings in the past?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-last-surrogate\" data-orig_data_id=\"group-last-surrogate\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"last-surrogation-date\"><input type=\"date\" name=\"last-surrogation-date\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">event<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">When was the last gestational carrying?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-last-surrogate\" data-orig_data_id=\"group-last-surrogate\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"last-surrogation-clinic\"><input type=\"text\" name=\"last-surrogation-clinic\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">event<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Name of IVF clinic for the last gestational carrying<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"was-egg-donor\"><select name=\"was-egg-donor\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever been an egg donor before?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-egg-donor-history\" data-orig_data_id=\"group-egg-donor-history\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"past-donations\"><input type=\"number\" name=\"past-donations\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How many egg donations in the past?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-egg-donor-history\" data-orig_data_id=\"group-egg-donor-history\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"last-donation\"><input type=\"date\" name=\"last-donation\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">event<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">When was the last egg donation?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"any-availability-restriction\"><select name=\"any-availability-restriction\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Is there any restriction on your availability on being a gestational carrier?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-availability-restriction\" data-orig_data_id=\"group-availability-restriction\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"availability-restrictions\"><textarea name=\"availability-restrictions\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Restrictions<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"applied-elsewhere\"><select name=\"applied-elsewhere\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you applied to be a gestational carrier at another medical facility, law firm and\/or agency?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-applied-elsewhere\" data-orig_data_id=\"group-applied-elsewhere\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"applied-elsewhere-details\"><textarea name=\"applied-elsewhere-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please list the facility names<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<p>  \t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t<div class=\"cf7md-item cf7md-card mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t\t<div class=\"mdc-card\">\n\t\t\t\t\t\t\t\t\t\t\t<section class=\"cf7md-card-header\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<h3 class=\"cf7md-card-title cf7md-card-title--\">Education and Employment<\/h3>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<p class=\"cf7md-card-subtitle\">List your education and employment now and then<\/p>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/section>\n\t\t\t\t\t\t\t\t\t\t<section class=\"cf7md-card-body\">\n\t\t\t\t\t\t<div class=\"mdc-layout-grid__inner\">\n\t\t\t\t\t\t\t\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"highest-degree\"><select name=\"highest-degree\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"High school\">High school<\/option><option value=\"Associate\">Associate<\/option><option value=\"Bachelor\">Bachelor<\/option><option value=\"Master\">Master<\/option><option value=\"PhD (Doctor of Philosophy)\">PhD (Doctor of Philosophy)<\/option><option value=\"MD (Doctor of Medicine)\">MD (Doctor of Medicine)<\/option><option value=\"JD (Juris Doctor)\">JD (Juris Doctor)<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">school<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Highest degree earned or being pursued<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"school\"><input type=\"text\" name=\"school\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">school<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Name of school\/college<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"major\"><input type=\"text\" name=\"major\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">school<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Major<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"education-background\"><textarea name=\"education-background\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Education background (including all degrees in the past)<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<p>    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"current-income\"><input type=\"number\" name=\"current-income\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">local_atm<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Current income (in US dollars)<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"working-status\"><select name=\"working-status\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Employee\">Employee<\/option><option value=\"Student\">Student<\/option><option value=\"Independent contractor\">Independent contractor<\/option><option value=\"Employer\">Employer<\/option><option value=\"Unemployed\">Unemployed<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">work<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Working status<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<div data-id=\"group-current-employment\" data-orig_data_id=\"group-current-employment\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"current-job-title\"><input type=\"text\" name=\"current-job-title\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">work<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Job title<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-current-employment\" data-orig_data_id=\"group-current-employment\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"current-employer-name\"><input type=\"text\" name=\"current-employer-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">work<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Company name<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-current-employment\" data-orig_data_id=\"group-current-employment\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"current-employer-address\"><input type=\"text\" name=\"current-employer-address\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">work<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Company address<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"employment-history\"><textarea name=\"employment-history\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Employment history (including all jobs in the past)<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-partner-working-status\" data-orig_data_id=\"group-partner-working-status\"  data-class=\"wpcf7cf_group\">\n      \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"partner-working-status\"><select name=\"partner-working-status\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Employee\">Employee<\/option><option value=\"Student\">Student<\/option><option value=\"Independent contractor\">Independent contractor<\/option><option value=\"Employer\">Employer<\/option><option value=\"Unemployed\">Unemployed<\/option><\/select><\/span><br \/>\n      \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">work<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Your spouse\/partner's working status<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-partner-current-employment\" data-orig_data_id=\"group-partner-current-employment\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"partner-current-job-title\"><input type=\"text\" name=\"partner-current-job-title\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">work<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Job title<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-partner-current-employment\" data-orig_data_id=\"group-partner-current-employment\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"partner-current-employer-name\"><input type=\"text\" name=\"partner-current-employer-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">work<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Company name<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-partner-current-employment\" data-orig_data_id=\"group-partner-current-employment\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"partner-current-employer-address\"><input type=\"text\" name=\"partner-current-employer-address\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">work<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Company address<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-partner-current-income\" data-orig_data_id=\"group-partner-current-income\"  data-class=\"wpcf7cf_group\">\n      \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"partner-current-income\"><input type=\"number\" name=\"partner-current-income\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">local_atm<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Your spouse\/partner's current income (in US dollars)<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<p>    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"support-persons\"><input type=\"number\" name=\"support-persons\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How many persons to support (including yourself)?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n  \t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t<div class=\"cf7md-item cf7md-card mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t\t<div class=\"mdc-card\">\n\t\t\t\t\t\t\t\t\t\t\t<section class=\"cf7md-card-header\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<h3 class=\"cf7md-card-title cf7md-card-title--\">Medical History<\/h3>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<p class=\"cf7md-card-subtitle\">Please provide your health information<\/p>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/section>\n\t\t\t\t\t\t\t\t\t\t<section class=\"cf7md-card-body\">\n\t\t\t\t\t\t<div class=\"mdc-layout-grid__inner\">\n\t\t\t\t\t\t\t\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"smoke\"><select name=\"smoke\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Do you smoke?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<div data-id=\"group-smoke-history\" data-orig_data_id=\"group-smoke-history\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"smoke-years\"><input type=\"number\" name=\"smoke-years\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How many years have you been smoking?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"drink\"><select name=\"drink\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Do you drink alcohol?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-drink-history\" data-orig_data_id=\"group-drink-history\"  data-class=\"wpcf7cf_group\">\n       \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"drink-history\"><select name=\"drink-history\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Occasionally\">Occasionally<\/option><option value=\"Often\">Often<\/option><option value=\"Very often\">Very often<\/option><\/select><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How often do you drink?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<p>    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"other-smoke\"><select name=\"other-smoke\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Is anyone living with you smoking?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"other-drink\"><select name=\"other-drink\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Is anyone living with you excessively drinking?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"medication\"><select name=\"medication\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Are you taking medication?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-medication\" data-orig_data_id=\"group-medication\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"medication-problem\"><input type=\"text\" name=\"medication-problem\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate the prescribed or over the counter medication on a regular or continual basis<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"any-medical-issue\"><select name=\"any-medical-issue\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Are you having any medical issue?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-medical-issue\" data-orig_data_id=\"group-medical-issue\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"medical-issue-details\"><textarea name=\"medical-issue-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate the medical issues<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-9-desktop mdc-layout-grid__cell--span-6-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"any-eating-disorder\"><select name=\"any-eating-disorder\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you had any eating disorder?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-eating-disorder\" data-orig_data_id=\"group-eating-disorder\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"eating-disorder-details\"><textarea name=\"eating-disorder-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate the details<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"drug-alcohol-abuse\"><select name=\"drug-alcohol-abuse\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever had any problems with drug or alcohol abuse?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-drug-alcohol-abuse\" data-orig_data_id=\"group-drug-alcohol-abuse\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"drug-alcohol-abuse-details\"><textarea name=\"drug-alcohol-abuse-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate the details<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<p>    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"limit-drug-alcohol-use\"><select name=\"limit-drug-alcohol-use\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever been advised to limit your use of alcohol or any other drug?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"not-take-medical-test-advice\"><select name=\"not-take-medical-test-advice\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever been advised to have any medical test and or surgical procedure and failed to take such advice?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"iv-drug\"><select name=\"iv-drug\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever used IV (Intravenous therapy) drug?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"allergy\"><select name=\"allergy\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Do you have allergy?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-allergy-history\" data-orig_data_id=\"group-allergy-history\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"allergy-history\"><input type=\"text\" name=\"allergy-history\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Allergy in the past (including medicine names)<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"chronic-problem\"><select name=\"chronic-problem\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Do you have any chronic medical problem or condition?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-chronic-problem-history\" data-orig_data_id=\"group-chronic-problem-history\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"chronic-problem-history\"><input type=\"text\" name=\"chronic-problem-history\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate chronic issues<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"infectious-disease\"><select name=\"infectious-disease\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you had any infectious disease?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-infectious-disease-history\" data-orig_data_id=\"group-infectious-disease-history\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"infectious-diseases-history-recent\"><input type=\"text\" name=\"infectious-diseases-history-recent\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Infectious diseases in the past 5 years<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-infectious-disease-history\" data-orig_data_id=\"group-infectious-disease-history\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"infectious-diseases-history\"><input type=\"text\" name=\"infectious-diseases-history\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Infectious diseases 5 years ago<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"surgery\"><select name=\"surgery\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you had any surgery?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-surgery-history\" data-orig_data_id=\"group-surgery-history\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"surgery-history-recent\"><textarea name=\"surgery-history-recent\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Surgery in the past 5 years (including surgery date and purpose)<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-surgery-history\" data-orig_data_id=\"group-surgery-history\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"surgery-history\"><textarea name=\"surgery-history\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Surgery 5 years ago (including surgery date and purpose)<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"hospitalized\"><select name=\"hospitalized\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever been hospitalized for a reason other than surgery?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-hospitalized-history\" data-orig_data_id=\"group-hospitalized-history\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"hospitalization-history-recent\"><textarea name=\"hospitalization-history-recent\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Hospitalization in the past 5 years (including hospitalization date and purpose)<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-hospitalized-history\" data-orig_data_id=\"group-hospitalized-history\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"hospitalization-history\"><textarea name=\"hospitalization-history\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Hospitalization 5 years ago (including hospitalization date and purpose)<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n       <span class=\"wpcf7-form-control-wrap\" data-name=\"any-postpartum-depression\"><select name=\"any-postpartum-depression\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever experienced postpartum depression?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-postpartum-depression\" data-orig_data_id=\"group-postpartum-depression\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"postpartum-depression-details\"><textarea name=\"postpartum-depression-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate the details (including when and duration)<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n       <span class=\"wpcf7-form-control-wrap\" data-name=\"any-psychiatric-problem\"><select name=\"any-psychiatric-problem\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever had any other mental issue?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-any-psychiatric-problem\" data-orig_data_id=\"group-any-psychiatric-problem\"  data-class=\"wpcf7cf_group\">\n      \t\t<div class=\"cf7md-item cf7md-checkbox mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-list cf7md-list__stacked\">\n\t\t\t\t\t\t\t<label class=\"cf7md-label cf7md-label--static\">Which of the following mental issues have you had?*<\/label>\n\t\t\t\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"psychiatric-problem\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"psychiatric-problem&#091;&#093;\" value=\"Depression\" \/><span class=\"wpcf7-list-item-label\">Depression<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"psychiatric-problem&#091;&#093;\" value=\"Schizophrenia\" \/><span class=\"wpcf7-list-item-label\">Schizophrenia<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"psychiatric-problem&#091;&#093;\" value=\"Manic Depression\" \/><span class=\"wpcf7-list-item-label\">Manic Depression<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"psychiatric-problem&#091;&#093;\" value=\"Obsessive\/Compulsive Disorder\" \/><span class=\"wpcf7-list-item-label\">Obsessive\/Compulsive Disorder<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"psychiatric-problem&#091;&#093;\" value=\"Mania\" \/><span class=\"wpcf7-list-item-label\">Mania<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"psychiatric-problem&#091;&#093;\" value=\"Anorexia or Bulimia\" \/><span class=\"wpcf7-list-item-label\">Anorexia or Bulimia<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"psychiatric-problem&#091;&#093;\" value=\"Self-Mutilation\" \/><span class=\"wpcf7-list-item-label\">Self-Mutilation<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"psychiatric-problem&#091;&#093;\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/span><\/span><\/span><br \/>\n      \t\t\t<div style=\"display: none;\" class=\"cf7md-checkbox-html\">\n\t\t\t\t<div class=\"mdc-checkbox__background\">\n\t\t\t\t\t<svg class=\"mdc-checkbox__checkmark\" viewbox=\"0 0 24 24\">\n\t\t\t\t\t\t<path class=\"mdc-checkbox__checkmark-path\" fill=\"none\" d=\"M1.73,12.91 8.1,19.28 22.79,4.59\"\/>\n\t\t\t\t\t<\/svg>\n\t\t\t\t\t<div class=\"mdc-checkbox__mixedmark\"><\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-psychiatric-problem-history\" data-orig_data_id=\"group-psychiatric-problem-history\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"psychiatric-problem-history-recent\"><textarea name=\"psychiatric-problem-history-recent\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Psychiatric treatments in the past 6 months (including counseling date, purpose and medicine)<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-psychiatric-problem-history\" data-orig_data_id=\"group-psychiatric-problem-history\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"psychiatric-problem-history\"><textarea name=\"psychiatric-problem-history\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Psychiatric treatments 6 months ago (including counseling date, purpose, and medicine)<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"any-blood-transfusion\"><select name=\"any-blood-transfusion\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever received for blood transfusion?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-blood-transfusion\" data-orig_data_id=\"group-blood-transfusion\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"blood-transfusion-history\"><input type=\"text\" name=\"blood-transfusion-history\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate when and reason<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"blood-donation-rejection\"><select name=\"blood-donation-rejection\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever been rejected for blood donation?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-blood-donation-rejection\" data-orig_data_id=\"group-blood-donation-rejection\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"blood-donation-rejection-history\"><input type=\"text\" name=\"blood-donation-rejection-history\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate reasons for rejection<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<p>  \t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t<div class=\"cf7md-item cf7md-card mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t\t<div class=\"mdc-card\">\n\t\t\t\t\t\t\t\t\t\t\t<section class=\"cf7md-card-header\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<h3 class=\"cf7md-card-title cf7md-card-title--\">Reproductive History<\/h3>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<p class=\"cf7md-card-subtitle\">Please describe your reproduction and pregnancy history<\/p>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/section>\n\t\t\t\t\t\t\t\t\t\t<section class=\"cf7md-card-body\">\n\t\t\t\t\t\t<div class=\"mdc-layout-grid__inner\">\n\t\t\t\t\t\t\t\n     \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"period-days\"><input type=\"number\" name=\"period-days\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How many days does your period usually last?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"period-interval\"><input type=\"number\" name=\"period-interval\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How many days on average from one period to the next?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"period-bleeding\"><select name=\"period-bleeding\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Do you have bleeding between periods?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"menstrual-cycle\"><select name=\"menstrual-cycle\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Regular\">Regular<\/option><option value=\"Irregular\">Irregular<\/option><\/select><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How do you describe your menstrual cycle?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<div data-id=\"group-menstrual-cycle\" data-orig_data_id=\"group-menstrual-cycle\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"menstrual-cycle-reason\"><textarea name=\"menstrual-cycle-reason\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate reasons for irregularity<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<p>     \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"breast-feeding\"><select name=\"breast-feeding\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Are you pregnant or breast-feeding now?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"last-pap-test-date\"><input type=\"date\" name=\"last-pap-test-date\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">event<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">When was your last pap smear?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<div data-id=\"group-last-pap-test\" data-orig_data_id=\"group-last-pap-test\"  data-class=\"wpcf7cf_group\">\n       \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"last-pap-test-result\"><select name=\"last-pap-test-result\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Was your last Pap smear result within normal limits?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-last-pap-test-reason\" data-orig_data_id=\"group-last-pap-test-reason\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"last-pap-test-reason\"><textarea name=\"last-pap-test-reason\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please further describe<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<p>     \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"infertility\"><select name=\"infertility\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever been told that you are infertile?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"infertility-treatment\"><select name=\"infertility-treatment\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever seen doctor for infertility?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<div data-id=\"group-infertility-treatment\" data-orig_data_id=\"group-infertility-treatment\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"infertility-treatment-details\"><textarea name=\"infertility-treatment-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate when and how it got treated<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"uterine-cyst\"><select name=\"uterine-cyst\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever been diagnosed with ovarian or uterine cysts?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-uterine-cyst\" data-orig_data_id=\"group-uterine-cyst\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"uterine-cyst-details\"><textarea name=\"uterine-cyst-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate when and how it got treated<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n       <span class=\"wpcf7-form-control-wrap\" data-name=\"any-reproductive-illness\"><select name=\"any-reproductive-illness\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever had any sexually transmitted diseases (STD)?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-any-reproductive-illness\" data-orig_data_id=\"group-any-reproductive-illness\"  data-class=\"wpcf7cf_group\">\n       \t\t<div class=\"cf7md-item cf7md-checkbox mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-list cf7md-list__stacked\">\n\t\t\t\t\t\t\t<label class=\"cf7md-label cf7md-label--static\">Have you ever had any of the following diseases?*<\/label>\n\t\t\t\t\t\t<br \/>\n         <span class=\"wpcf7-form-control-wrap\" data-name=\"reproductive-illness\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"reproductive-illness&#091;&#093;\" value=\"Chlamydia\" \/><span class=\"wpcf7-list-item-label\">Chlamydia<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"reproductive-illness&#091;&#093;\" value=\"Gonorrhea\" \/><span class=\"wpcf7-list-item-label\">Gonorrhea<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"reproductive-illness&#091;&#093;\" value=\"AIDS\/HIV\" \/><span class=\"wpcf7-list-item-label\">AIDS\/HIV<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"reproductive-illness&#091;&#093;\" value=\"Tuberculosis\" \/><span class=\"wpcf7-list-item-label\">Tuberculosis<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"reproductive-illness&#091;&#093;\" value=\"Hepatitis A B C\" \/><span class=\"wpcf7-list-item-label\">Hepatitis A B C<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"reproductive-illness&#091;&#093;\" value=\"Syphilis\" \/><span class=\"wpcf7-list-item-label\">Syphilis<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"reproductive-illness&#091;&#093;\" value=\"Venereal Warts\" \/><span class=\"wpcf7-list-item-label\">Venereal Warts<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"reproductive-illness&#091;&#093;\" value=\"Herpes\" \/><span class=\"wpcf7-list-item-label\">Herpes<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"reproductive-illness&#091;&#093;\" value=\"Pelvic Inflammatory Disease\" \/><span class=\"wpcf7-list-item-label\">Pelvic Inflammatory Disease<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"reproductive-illness&#091;&#093;\" value=\"Abnormal Pap Smear\" \/><span class=\"wpcf7-list-item-label\">Abnormal Pap Smear<\/span><\/span><\/span><\/span><br \/>\n       \t\t\t<div style=\"display: none;\" class=\"cf7md-checkbox-html\">\n\t\t\t\t<div class=\"mdc-checkbox__background\">\n\t\t\t\t\t<svg class=\"mdc-checkbox__checkmark\" viewbox=\"0 0 24 24\">\n\t\t\t\t\t\t<path class=\"mdc-checkbox__checkmark-path\" fill=\"none\" d=\"M1.73,12.91 8.1,19.28 22.79,4.59\"\/>\n\t\t\t\t\t<\/svg>\n\t\t\t\t\t<div class=\"mdc-checkbox__mixedmark\"><\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-reproductive-illness\" data-orig_data_id=\"group-reproductive-illness\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"reproductive-illness-details\"><textarea name=\"reproductive-illness-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please describe when the illness occurred and how it got treated<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"pregnancy\"><select name=\"pregnancy\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever been pregnant?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-pregnant-times\" data-orig_data_id=\"group-pregnant-times\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"pregnancy-times\"><input type=\"number\" name=\"pregnancy-times\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How many times of pregnancy?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-pregnant-years\" data-orig_data_id=\"group-pregnant-years\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"pregnancy-years\"><input type=\"text\" name=\"pregnancy-years\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Which years did those pregnancy occur?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-miscarriage\" data-orig_data_id=\"group-miscarriage\"  data-class=\"wpcf7cf_group\">\n       \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"miscarriage\"><select name=\"miscarriage\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever had any miscarriage?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-miscarriage-times\" data-orig_data_id=\"group-miscarriage-times\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"miscarriage-times\"><input type=\"number\" name=\"miscarriage-times\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Number of miscarriages<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-miscarriage-years\" data-orig_data_id=\"group-miscarriage-years\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"miscarriage-years\"><input type=\"text\" name=\"miscarriage-years\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Years of those miscarriages<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-abortion\" data-orig_data_id=\"group-abortion\"  data-class=\"wpcf7cf_group\">\n       \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"abortion\"><select name=\"abortion\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you had any abortion?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-abortion-times\" data-orig_data_id=\"group-abortion-times\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"abortion-times\"><input type=\"number\" name=\"abortion-times\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Number of abortions<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-abortion-years\" data-orig_data_id=\"group-abortion-years\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"abortion-years\"><input type=\"text\" name=\"abortion-years\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Years of those abortions<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-stillbirth\" data-orig_data_id=\"group-stillbirth\"  data-class=\"wpcf7cf_group\">\n       \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n         <span class=\"wpcf7-form-control-wrap\" data-name=\"stillbirth\"><select name=\"stillbirth\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n       \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you had any stillbirth?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-stillbirth-times\" data-orig_data_id=\"group-stillbirth-times\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"stillbirth-times\"><input type=\"number\" name=\"stillbirth-times\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Number of stillbirths<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-stillbirth-years\" data-orig_data_id=\"group-stillbirth-years\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"stillbirth-years\"><input type=\"text\" name=\"stillbirth-years\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Years of those stillbirths<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-delivery\" data-orig_data_id=\"group-delivery\"  data-class=\"wpcf7cf_group\">\n       \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n         <span class=\"wpcf7-form-control-wrap\" data-name=\"delivery\"><select name=\"delivery\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n       \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you had deliveries?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-delivery-times\" data-orig_data_id=\"group-delivery-times\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"delivery-times\"><input type=\"number\" name=\"delivery-times\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Number of deliveries<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-delivery-years\" data-orig_data_id=\"group-delivery-years\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"delivery-years\"><input type=\"text\" name=\"delivery-years\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Years of those deliveries<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-delivery-children\" data-orig_data_id=\"group-delivery-children\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"delivery-children\"><input type=\"text\" name=\"delivery-children\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Weight and sex of delivered babies<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-delivery-defect\" data-orig_data_id=\"group-delivery-defect\"  data-class=\"wpcf7cf_group\">\n       \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"delivery-defect\"><select name=\"delivery-defect\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n       \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you had pregnancies with birth defects?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-delivery-defect-details\" data-orig_data_id=\"group-delivery-defect-details\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"delivery-defect-details\"><textarea name=\"delivery-defect-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please explain<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"sexually-active\"><select name=\"sexually-active\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Are you currently sexually active?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-sexually-active\" data-orig_data_id=\"group-sexually-active\"  data-class=\"wpcf7cf_group\">\n       \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-select--multi\">\n\t\t\t<br \/>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"multiple-sex-partner\"><select name=\"multiple-sex-partner\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n       \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Do you currently have more than one sexual partner?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-sexually-active\" data-orig_data_id=\"group-sexually-active\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"months-current-sex-partner\"><input type=\"number\" name=\"months-current-sex-partner\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How many months have you been with your current partner(s)?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-sexually-active\" data-orig_data_id=\"group-sexually-active\"  data-class=\"wpcf7cf_group\">\n       \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"curr-relationship-monogamous\"><select name=\"curr-relationship-monogamous\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n       \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Is your current relationship monogamous?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<p>     \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"number-partners\"><input type=\"number\" name=\"number-partners\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How many partners have you had in the past one year?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n       <span class=\"wpcf7-form-control-wrap\" data-name=\"sexual-contacts\"><select name=\"sexual-contacts\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Men Only\">Men Only<\/option><option value=\"Women Only\">Women Only<\/option><option value=\"Both\">Both<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate persons you have had sexual contact with<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"stranger-partner\"><select name=\"stranger-partner\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you had sexual contact with a person you do not know well? <\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"std-partner\"><select name=\"std-partner\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever been with a partner who was tested positive for sexual transmitted diseases (STD)? <\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<div data-id=\"group-std-partner\" data-orig_data_id=\"group-std-partner\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"std-partner-details\"><textarea name=\"std-partner-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please further describe<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"birth-control\"><select name=\"birth-control\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever taken, or are you currently taking any birth control pills?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-birth-control\" data-orig_data_id=\"group-birth-control\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"birth-control-reason\"><textarea name=\"birth-control-reason\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate when and reasons<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n       <span class=\"wpcf7-form-control-wrap\" data-name=\"any-contraception\"><select name=\"any-contraception\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you ever used any contraception in the last six months?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-any-contraception\" data-orig_data_id=\"group-any-contraception\"  data-class=\"wpcf7cf_group\">\n       \t\t<div class=\"cf7md-item cf7md-checkbox mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-list cf7md-list__stacked\">\n\t\t\t\t\t\t\t<label class=\"cf7md-label cf7md-label--static\">What method of contraception have you used in the last six months?*<\/label>\n\t\t\t\t\t\t<br \/>\n         <span class=\"wpcf7-form-control-wrap\" data-name=\"contraception\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"contraception&#091;&#093;\" value=\"Pills\" \/><span class=\"wpcf7-list-item-label\">Pills<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"contraception&#091;&#093;\" value=\"IUD\" \/><span class=\"wpcf7-list-item-label\">IUD<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"contraception&#091;&#093;\" value=\"Condom\" \/><span class=\"wpcf7-list-item-label\">Condom<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"contraception&#091;&#093;\" value=\"Norplant\" \/><span class=\"wpcf7-list-item-label\">Norplant<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"contraception&#091;&#093;\" value=\"Depo\" \/><span class=\"wpcf7-list-item-label\">Depo<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"contraception&#091;&#093;\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/span><\/span><\/span><br \/>\n       \t\t\t<div style=\"display: none;\" class=\"cf7md-checkbox-html\">\n\t\t\t\t<div class=\"mdc-checkbox__background\">\n\t\t\t\t\t<svg class=\"mdc-checkbox__checkmark\" viewbox=\"0 0 24 24\">\n\t\t\t\t\t\t<path class=\"mdc-checkbox__checkmark-path\" fill=\"none\" d=\"M1.73,12.91 8.1,19.28 22.79,4.59\"\/>\n\t\t\t\t\t<\/svg>\n\t\t\t\t\t<div class=\"mdc-checkbox__mixedmark\"><\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\n     <\/div>\n<div data-id=\"group-contraception\" data-orig_data_id=\"group-contraception\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"contraception-details\"><textarea name=\"contraception-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please further explain (if IUD or Other checked)<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<p>  \t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t<div class=\"cf7md-item cf7md-card mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t\t<div class=\"mdc-card\">\n\t\t\t\t\t\t\t\t\t\t\t<section class=\"cf7md-card-header\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<h3 class=\"cf7md-card-title cf7md-card-title--\">Survey on Gestational Carrying<\/h3>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<p class=\"cf7md-card-subtitle\">Tell us your opinions about being a gestational carrier<\/p>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/section>\n\t\t\t\t\t\t\t\t\t\t<section class=\"cf7md-card-body\">\n\t\t\t\t\t\t<div class=\"mdc-layout-grid__inner\">\n\t\t\t\t\t\t\t\n     \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"why-gc\"><select name=\"why-gc\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"I like being pregnant, but don\u2019t want children of my own\">I like being pregnant, but don\u2019t want children of my own<\/option><option value=\"I need the money\">I need the money<\/option><option value=\"Bringing an infertile couple a child brings me happiness\">Bringing an infertile couple a child brings me happiness<\/option><option value=\"Other\">Other<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Why do you decide to be a gestational carrier?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<div data-id=\"group-why-gc\" data-orig_data_id=\"group-why-gc\"  data-class=\"wpcf7cf_group\">\n        \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"why-gc-other\"><input type=\"text\" name=\"why-gc-other\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field\">\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please further explain<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n       <span class=\"wpcf7-form-control-wrap\" data-name=\"family-know-decision\"><select name=\"family-know-decision\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Have you told your family or partner about your decision?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-family-know-decision\" data-orig_data_id=\"group-family-know-decision\"  data-class=\"wpcf7cf_group\">\n        \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"family-know-decision-details\"><textarea name=\"family-know-decision-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate their opinions<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n       <span class=\"wpcf7-form-control-wrap\" data-name=\"not-gc\"><select name=\"not-gc\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Is there any type of parents whom you will not work with?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-not-gc\" data-orig_data_id=\"group-not-gc\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"not-gc-details\"><textarea name=\"not-gc-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please further describe<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<p>     \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"support-details\"><textarea name=\"support-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">What kind of support do you expect from your family, intended parents, and agent?<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n       <span class=\"wpcf7-form-control-wrap\" data-name=\"carrying-twins\"><select name=\"carrying-twins\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Unsure\">Unsure<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Are you willing to carry twins?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n       <span class=\"wpcf7-form-control-wrap\" data-name=\"carrying-triplets\"><select name=\"carrying-triplets\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Unsure\">Unsure<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Are you willing to carry triplets?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"parents-in-delivery-room\"><select name=\"parents-in-delivery-room\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Unsure\">Unsure<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Would you permit intended parents to attend doctor\u2019s appointments if they want to?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"diagnostic-testing-ok\"><select name=\"diagnostic-testing-ok\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Unsure\">Unsure<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Are you willing to undergo amniocentesis or other diagnostic testing to check birth defect?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"abortion-ok\"><select name=\"abortion-ok\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Unsure\">Unsure<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Are you willing to abort in case of serious problem with fetus and being requested by intended parents?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"no-abortion\"><select name=\"no-abortion\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Is there any situation you will not abort pregnancy, despite the request by intended parents?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<div data-id=\"group-no-abortion\" data-orig_data_id=\"group-no-abortion\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"no-abortion-details\"><textarea name=\"no-abortion-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate such situations<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<p>    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"parents-in-delivery\"><select name=\"parents-in-delivery\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Unsure\">Unsure<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Do you allow intended parents to be in the delivery room?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"parents-notify\"><select name=\"parents-notify\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Unsure\">Unsure<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Do you allow intended parents to notify the hospital that you are not the biological mother?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"parents-in-birth-cert\"><select name=\"parents-in-birth-cert\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Unsure\">Unsure<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Do you allow the intended parents names to be placed on the birth certificate?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"breast-milk\"><select name=\"breast-milk\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Unsure\">Unsure<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Are you be willing to pump, freeze and ship your breast milk if intended parents request?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"give-up-child\"><select name=\"give-up-child\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Unsure\">Unsure<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Are you confident that you will not hesitate to give intended parents child(ren) you will carry?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"keep-contact\"><select name=\"keep-contact\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Definitely\">Definitely<\/option><option value=\"Not at all\">Not at all<\/option><option value=\"Up to intended parents\">Up to intended parents<\/option><option value=\"Unsure\">Unsure<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">After birth, do you want to keep contact with delivered child and intended parents?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<p>  \t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t<div class=\"cf7md-item cf7md-card mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t\t<div class=\"mdc-card\">\n\t\t\t\t\t\t\t\t\t\t\t<section class=\"cf7md-card-header\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<h3 class=\"cf7md-card-title cf7md-card-title--\">Family<\/h3>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<p class=\"cf7md-card-subtitle\">Tell us general health condition of your family members<\/p>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/section>\n\t\t\t\t\t\t\t\t\t\t<section class=\"cf7md-card-body\">\n\t\t\t\t\t\t<div class=\"mdc-layout-grid__inner\">\n\t\t\t\t\t\t\t\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n       <span class=\"wpcf7-form-control-wrap\" data-name=\"any-children\"><select name=\"any-children\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Do you have any children who is biologically related to you?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<div data-id=\"group-children\" data-orig_data_id=\"group-children\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"children-boys\"><input type=\"text\" name=\"children-boys\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How many boys and their ages<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-children\" data-orig_data_id=\"group-children\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"children-girls\"><input type=\"text\" name=\"children-girls\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How many girls and their ages<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-children-death\" data-orig_data_id=\"group-children-death\"  data-class=\"wpcf7cf_group\">\n       \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n           <span class=\"wpcf7-form-control-wrap\" data-name=\"any-dead-children\"><select name=\"any-dead-children\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n       \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Was any of your biological children deceased?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-children-death-details\" data-orig_data_id=\"group-children-death-details\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t<br \/>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"children-death-details\"><textarea name=\"children-death-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span><br \/>\n       \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate death age and cause<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-children-defect\" data-orig_data_id=\"group-children-defect\"  data-class=\"wpcf7cf_group\">\n       \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n           <span class=\"wpcf7-form-control-wrap\" data-name=\"any-defective-children\"><select name=\"any-defective-children\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n       \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Does any of your biological children have birth defect or serious health problem?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-children-defect-details\" data-orig_data_id=\"group-children-defect-details\"  data-class=\"wpcf7cf_group\">\n       \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t<br \/>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"children-issue-details\"><textarea name=\"children-issue-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span><br \/>\n       \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate details<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n       <span class=\"wpcf7-form-control-wrap\" data-name=\"any-more-children\"><select name=\"any-more-children\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Do you want to have (more) children in the future?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n\t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"sibling-number\"><input type=\"number\" name=\"sibling-number\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How many siblings do you have?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-sibling\" data-orig_data_id=\"group-sibling\"  data-class=\"wpcf7cf_group\">\n      \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"silbling-brothers\"><input type=\"number\" name=\"silbling-brothers\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n      \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How many brothers?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-sibling\" data-orig_data_id=\"group-sibling\"  data-class=\"wpcf7cf_group\">\n      \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"silbling-sisters\"><input type=\"number\" name=\"silbling-sisters\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n      \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How many sisters?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-sibling\" data-orig_data_id=\"group-sibling\"  data-class=\"wpcf7cf_group\">\n      \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"sibling-health-issue\"><select name=\"sibling-health-issue\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Unknown\">Unknown<\/option><\/select><\/span><br \/>\n      \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Do they have any health or mental issue?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<div data-id=\"group-sibling-health-issue\" data-orig_data_id=\"group-sibling-health-issue\"  data-class=\"wpcf7cf_group\">\n      \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"sibling-health-issue-details\"><textarea name=\"sibling-health-issue-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<p>    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-9-desktop mdc-layout-grid__cell--span-6-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"mother-race\"><select name=\"mother-race\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"American Indian or Alaska Native\">American Indian or Alaska Native<\/option><option value=\"Asian\">Asian<\/option><option value=\"Black or African American\">Black or African American<\/option><option value=\"Hispanic or Latino\">Hispanic or Latino<\/option><option value=\"Native Hawaiian or Other Pacific Islander\">Native Hawaiian or Other Pacific Islander<\/option><option value=\"White\">White<\/option><option value=\"Other\">Other<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Mother's ethnicity (Select Other for mixed-ethnicity)<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"mother-alive\"><select name=\"mother-alive\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Unknown\">Unknown<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Is she alive?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"mother-age\"><input type=\"number\" name=\"mother-age\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Her age (Current or At-death)<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"mother-blood\"><select name=\"mother-blood\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"A\">A<\/option><option value=\"B\">B<\/option><option value=\"AB\">AB<\/option><option value=\"O\">O<\/option><option value=\"Unknown\">Unknown<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Her blood type<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"mother-blood-rh\"><select name=\"mother-blood-rh\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"Positive\">Positive<\/option><option value=\"Negative\">Negative<\/option><option value=\"Unknown\">Unknown<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Her blood RH factor<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"mother-height\"><input type=\"text\" name=\"mother-height\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Her height (foot'inch)<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"mother-weight\"><input type=\"number\" name=\"mother-weight\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Her weight (lb)<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"mother-health-issue\"><select name=\"mother-health-issue\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Unknown\">Unknown<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Does she have any health or mental issue?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<div data-id=\"group-mother-health-issue\" data-orig_data_id=\"group-mother-health-issue\"  data-class=\"wpcf7cf_group\">\n      \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"mother-health-issue-details\"><textarea name=\"mother-health-issue-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<p>    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-9-desktop mdc-layout-grid__cell--span-6-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"father-race\"><select name=\"father-race\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"American Indian or Alaska Native\">American Indian or Alaska Native<\/option><option value=\"Asian\">Asian<\/option><option value=\"Black or African American\">Black or African American<\/option><option value=\"Hispanic or Latino\">Hispanic or Latino<\/option><option value=\"Native Hawaiian or Other Pacific Islander\">Native Hawaiian or Other Pacific Islander<\/option><option value=\"White\">White<\/option><option value=\"Other\">Other<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Father's ethnicity (Select Other for mixed-ethnicity)<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"father-alive\"><select name=\"father-alive\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Unknown\">Unknown<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Is he alive?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"father-age\"><input type=\"number\" name=\"father-age\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">His age (Current or At-death)<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"father-blood\"><select name=\"father-blood\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"A\">A<\/option><option value=\"B\">B<\/option><option value=\"AB\">AB<\/option><option value=\"O\">O<\/option><option value=\"Unknown\">Unknown<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">His blood type<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"father-blood-rh\"><select name=\"father-blood-rh\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"Positive\">Positive<\/option><option value=\"Negative\">Negative<\/option><option value=\"Unknown\">Unknown<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">His blood RH factor<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"father-height\"><input type=\"text\" name=\"father-height\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">His height (foot'inch)<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"father-weight\"><input type=\"number\" name=\"father-weight\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">person<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">His weight (lb)<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"father-health-issue\"><select name=\"father-health-issue\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Unknown\">Unknown<\/option><\/select><\/span><br \/>\n    \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Does he have any health or mental issue?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<div data-id=\"group-father-health-issue\" data-orig_data_id=\"group-father-health-issue\"  data-class=\"wpcf7cf_group\">\n      \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"father-health-issue-details\"><textarea name=\"father-health-issue-details\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please indicate<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n    <\/div>\n<p>  \t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t<div class=\"cf7md-item cf7md-card mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t\t<div class=\"mdc-card\">\n\t\t\t\t\t\t\t\t\t\t\t<section class=\"cf7md-card-header\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<h3 class=\"cf7md-card-title cf7md-card-title--\">Personality<\/h3>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<p class=\"cf7md-card-subtitle\">Tell us what you like and dislike, and what you wish to do<\/p>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/section>\n\t\t\t\t\t\t\t\t\t\t<section class=\"cf7md-card-body\">\n\t\t\t\t\t\t<div class=\"mdc-layout-grid__inner\">\n\t\t\t\t\t\t\t\n     \n\t\t<div class=\"cf7md-item cf7md-textarea mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone cf7md-textarea-autosize\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"describe-yourself\"><textarea name=\"describe-yourself\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--textarea\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"mdc-notched-outline\">\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__leading\"><\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__notch\">\n\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Please describe yourself<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mdc-notched-outline__trailing\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"personality-strength\"><input type=\"text\" name=\"personality-strength\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Your personality strength<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"personality-weakness\"><input type=\"text\" name=\"personality-weakness\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Your personality weakness<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"personal-achievement\"><input type=\"text\" name=\"personal-achievement\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Your greatest achievements<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"hobbies\"><input type=\"text\" name=\"hobbies\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Your hobbies<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"favorite-music\"><input type=\"text\" name=\"favorite-music\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Your favorite music<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"favorite-books\"><input type=\"text\" name=\"favorite-books\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Your favorite books<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"favorite-sports\"><input type=\"text\" name=\"favorite-sports\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Your favorite sports<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"favorite-food\"><input type=\"text\" name=\"favorite-food\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Your favorite food<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t <\/p>\n<p>     \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n       <span class=\"wpcf7-form-control-wrap\" data-name=\"vegetarian\"><select name=\"vegetarian\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Are you a vegetarian?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n     \t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n       <span class=\"wpcf7-form-control-wrap\" data-name=\"own-pet\"><select name=\"own-pet\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Do you own a pet?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n\t\t<div class=\"cf7md-item cf7md-select mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<br \/>\n       <span class=\"wpcf7-form-control-wrap\" data-name=\"exercise\"><select name=\"exercise\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"Never\">Never<\/option><option value=\"Once per week\">Once per week<\/option><option value=\"Two to three times per week\">Two to three times per week<\/option><option value=\"Everyday\">Everyday<\/option><\/select><\/span><br \/>\n     \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-select-html\">\n\t\t\t\t<div class=\"mdc-select  mdc-select--box mdc-select--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-select__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t<i class=\"mdc-select__dropdown-icon\"><\/i>\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">How often do you exercise?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n<div data-id=\"group-exercise\" data-orig_data_id=\"group-exercise\"  data-class=\"wpcf7cf_group\">\n       \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"exercise-details\"><input type=\"text\" name=\"exercise-details\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> \t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">question_answer<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">What type of exercise do you do?<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n     <\/div>\n<p>  \t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t<div class=\"cf7md-item cf7md-card mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t\t<div class=\"mdc-card\">\n\t\t\t\t\t\t\t\t\t\t\t<section class=\"cf7md-card-header\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<h3 class=\"cf7md-card-title cf7md-card-title--\">Surrogate Mother Agreement<\/h3>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<p class=\"cf7md-card-subtitle\">Please check acknowledgement checkbox and type your name if you consent<\/p>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/section>\n\t\t\t\t\t\t\t\t\t\t<section class=\"cf7md-card-body\">\n\t\t\t\t\t\t<div class=\"mdc-layout-grid__inner\">\n\t\t\t\t\t\t\t\n    \t\t<div class=\"cf7md-item cf7md-accept cf7md-is-wpcf7v5 mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"consent\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"consent\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">I acknowledge that I have read and fully consent to <a href=\"\" style=\"color:#FF00FF;\" class=\"spu-open-241\">Surrogate Mother Agreement<\/a>.<\/span><\/label><\/span><\/span><\/span> \t\t\t<label class=\"cf7md-accept-label\"><\/label>\n\t\t\t<div style=\"display: none;\" class=\"cf7md-checkbox-html\">\n\t\t\t\t<div class=\"mdc-checkbox__background\">\n\t\t\t\t\t<svg class=\"mdc-checkbox__checkmark\" viewbox=\"0 0 24 24\">\n\t\t\t\t\t\t<path class=\"mdc-checkbox__checkmark-path\" fill=\"none\" d=\"M1.73,12.91 8.1,19.28 22.79,4.59\"\/>\n\t\t\t\t\t<\/svg>\n\t\t\t\t\t<div class=\"mdc-checkbox__mixedmark\"><\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"consent-signature\"><input type=\"text\" name=\"consent-signature\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">edit<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Type your legal name<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n    \t\t\n\t\t<div class=\"cf7md-item cf7md-text mdc-layout-grid__cell mdc-layout-grid__cell--span-6-desktop mdc-layout-grid__cell--span-4-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"consent-date\"><input type=\"date\" name=\"consent-date\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\t\t\t\t\t\t<div style=\"display: none;\" class=\"cf7md-text-html\">\n\t\t\t\t<div class=\"mdc-text-field  mdc-text-field--with-leading-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<i class=\"material-icons mdc-text-field__icon\">event<\/i>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"mdc-floating-label\">Enter today's date<\/label>\n\t\t\t\t\t\t<div class=\"mdc-line-ripple\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<br \/>\n  \t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\n<p>  <span id=\"wpcf7-69ee4f9829de4-wrapper\" class=\"wpcf7-form-control-wrap website-wrap\" ><label for=\"wpcf7-69ee4f9829de4-field\" class=\"hp-message\">Please leave this field empty.<\/label><input id=\"wpcf7-69ee4f9829de4-field\"  class=\"wpcf7-form-control wpcf7-text\" type=\"text\" name=\"website\" value=\"\" size=\"40\" tabindex=\"-1\" autocomplete=\"new-password\" \/><\/span><\/p>\n<p>  \t\t<div class=\"cf7md-item cf7md-submit mdc-layout-grid__cell mdc-layout-grid__cell--span-12-desktop mdc-layout-grid__cell--span-8-tablet mdc-layout-grid__cell--span-4-phone\" data-button-style=\"raised\">\n\t\t\t<input type=\"submit\" value=\"Submit\" class=\"wpcf7-form-control has-spinner wpcf7-submit\" \/>\t\t\t<svg class=\"cf7md-spinner\" width=\"25px\" height=\"25px\" viewbox=\"0 0 66 66\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n\t\t\t\t<circle class=\"cf7md-spinner-path\" fill=\"none\" stroke-width=\"6\" stroke-linecap=\"round\" cx=\"33\" cy=\"33\" r=\"30\"><\/circle>\n\t\t\t<\/svg>\n\t\t<\/div>\n\t\t<br \/>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/p>\n<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><input type=\"hidden\" name=\"trp-form-language\" value=\"zh\"\/><\/form><\/div><\/p>\r\n<p><audio style=\"display: none;\" controls=\"controls\"><\/audio><\/p>\r\n<p><audio style=\"display: none;\" controls=\"controls\"><\/audio><\/p>\t\t\t\t<\/div>\r\n\t\t\t\t\r\n\t\t\t\t  \r\n\t\t<\/div>\r\n\t\t\r\n\t<\/div> \r\n<\/div>","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_mi_skip_tracking":false},"_links":{"self":[{"href":"https:\/\/dawnermedicalservices.com\/zh\/wp-json\/wp\/v2\/pages\/147"}],"collection":[{"href":"https:\/\/dawnermedicalservices.com\/zh\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/dawnermedicalservices.com\/zh\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/dawnermedicalservices.com\/zh\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/dawnermedicalservices.com\/zh\/wp-json\/wp\/v2\/comments?post=147"}],"version-history":[{"count":4,"href":"https:\/\/dawnermedicalservices.com\/zh\/wp-json\/wp\/v2\/pages\/147\/revisions"}],"predecessor-version":[{"id":693,"href":"https:\/\/dawnermedicalservices.com\/zh\/wp-json\/wp\/v2\/pages\/147\/revisions\/693"}],"wp:attachment":[{"href":"https:\/\/dawnermedicalservices.com\/zh\/wp-json\/wp\/v2\/media?parent=147"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}