{"id":92,"date":"2020-07-03T21:01:28","date_gmt":"2020-07-03T21:01:28","guid":{"rendered":"http:\/\/sailingmedicalservices.com\/?page_id=92"},"modified":"2024-08-07T04:03:37","modified_gmt":"2024-08-07T04:03:37","slug":"egg-donor-candidate","status":"publish","type":"page","link":"https:\/\/dawnermedicalservices.com\/zh\/egg-donor-candidate\/","title":{"rendered":"Egg Donor Candidate"},"content":{"rendered":"<style>\r\n\t.wpsm_tab_297 .wpsm_nav-tabs li a,\r\n\t.wpsm_tab_297 .wpsm_nav-tabs li a:hover,\r\n\t.wpsm_tab_297 .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_297 a,\r\n\t#wpsm_tab_container_297 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_297{\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_297 ul{\r\n\t\tpadding:0;\r\n\t\tmargin:0;\r\n\t}\r\n\t.wpsm_tab_297 .wpsm_nav-tabs li{\r\n\t\tmargin-left:0;\r\n\t}\r\n\t.wpsm_tab_297 .wpsm_nav-tabs li a i{\r\n\t\theight:auto;\r\n\t}\r\n\t#wpsm_tab_container_297 .wpsm_nav li .wpsm_tabs_img_icon,\r\n\t#wpsm_tab_container_297 .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_297 .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_297 .wpsm_tab_297 .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_297 .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_297 .wpsm_tab_297 .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_297 .wpsm_nav-tabs li a i,\r\n\t.wpsm_tab_297 .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_297 .wpsm_nav-tabs li a,\r\n.wpsm_tab_297 a:hover,\r\n.wpsm_tab_297 a:focus{\r\n    outline: none;\r\n    text-decoration: none;\r\n}\r\n.wpsm_tab_297 .wpsm_nav-tabs{\r\n    background: transparent;\r\n\tborder-bottom:0px;\r\n}\r\n.wpsm_tab_297 .wpsm_nav-tabs li{\r\n    text-align: center;\r\n    margin-right: 0px;\r\n}\r\n.wpsm_tab_297 .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_297 .wpsm_nav-tabs li.active a,\r\n.wpsm_tab_297 .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_297 .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_297 .wpsm_nav-tabs li.active a i,\r\n.wpsm_tab_297 .wpsm_nav-tabs li a:hover i{\r\n\tcolor: #ea7066 !important;\r\n}\r\n.wpsm_tab_297 .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_297 .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_297 .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_297 .wpsm_nav-tabs li{ \r\n\t\twidth: 100% !important; \r\n\t}\r\n\t\t\t.wpsm_tab_297 .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_297\">\r\n\t<div class=\"wpsm_tab_297\"  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_297\">\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_297_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_297_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_297_1\">\r\n\t\t\t\t\t<p style=\"text-align: left;\">Egg donation is a gift that lasts a lifetime. By becoming an egg donor, you will help individuals or couples create the families they have longed for. The process requires a few weeks of diligence and attention but involves minimal discomfort or pain. We encourage you to read through 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 egg donor coordinator is available to answer your questions and assist you throughout the application process.<\/p>\r\n<p><b class=\"collapseomatic\" id=\"id69ee4d2a3c942\"  tabindex=\"0\" title=\"Why Egg Donation\"    >Why Egg Donation<\/b><div id=\"target-id69ee4d2a3c942\" class=\"collapseomatic_content\"><\/p>\r\n<p style=\"text-align: left;\">For some couples, egg donation is the only option for achieving pregnancy. Reasons why a woman might choose egg donation include:<\/p>\r\n<ul style=\"text-align: left;\">\r\n<li style=\"text-align: left;\">Chemotherapy<\/li>\r\n<li>Premature menopause or\u00a0premature ovarian failure<\/li>\r\n<li>Genetic issues<\/li>\r\n<\/ul>\r\n<p>Imagine if the recipient were your sister or a friend. As an egg donor, you are generously providing a couple with a wonderful gift.<\/p>\r\n<p><\/div><\/p>\r\n<p><b class=\"collapseomatic\" id=\"id69ee4d2a3c977\"  tabindex=\"0\" title=\"Understanding Egg Donation\"    >Understanding Egg Donation<\/b><div id=\"target-id69ee4d2a3c977\" class=\"collapseomatic_content\"><\/p>\r\n<p>\u200b\u200bThe egg donation process can be strictly anonymous. Your privacy is highly respected, and recipients will not receive any identity information about you. You will neither meet the recipients nor be informed of the outcome of the process. All screening and treatment are conducted confidentially. The newborn resulting from your donated egg will become the legal child of the recipients, and you will have no further obligations.<\/p>\r\n<p><\/div><\/p>\r\n<p><b class=\"collapseomatic\" id=\"id69ee4d2a3c986\"  tabindex=\"0\" title=\"Egg Donation Cycle\"    >Egg Donation Cycle<\/b><div id=\"target-id69ee4d2a3c986\" class=\"collapseomatic_content\"><\/p>\r\n<div id=\"wsb-canvas-template-container\">\r\n<div id=\"wsb-element-479c0472-474a-4342-84ab-110fe74677bc\" class=\"wsb-element-text\" data-type=\"element\">\r\n<div class=\"txt\">In general, an egg donation cycle takes 4 to 6 weeks to complete, excluding the matching and screening phases. Egg donation is typically combined with IVF (In Vitro Fertilization). During this process, eggs are retrieved from the donor and fertilized in the laboratory with sperm from the recipient\u2019s spouse, partner, or a sperm donor to stimulate embryo development. The embryos are then transferred to the female recipient or gestational carrier. A typical egg donation process includes:<br \/>\r\n<ul>\r\n<li>Matching<\/li>\r\n<li>Screening<\/li>\r\n<li>Cycle Synchronization<\/li>\r\n<li>FDA appointment<\/li>\r\n<li>Stimulation Treatment<\/li>\r\n<li>Egg Retrieval<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<p><\/div><\/p>\r\n<div id=\"wsb-canvas-template-container\">\r\n<div id=\"wsb-element-479c0472-474a-4342-84ab-110fe74677bc\" class=\"wsb-element-text\" data-type=\"element\">\r\n<div class=\"txt\">\r\n<p><b class=\"collapseomatic\" id=\"id69ee4d2a3c992\"  tabindex=\"0\" title=\"More about Egg Retrieval\"    >More about Egg Retrieval<\/b><div id=\"target-id69ee4d2a3c992\" class=\"collapseomatic_content\"><\/p>\r\n<p>The official name of this procedure is Ultrasound-Guided Needle Follicular Aspiration. You will be placed under sedation and will remain asleep throughout the procedure. A vaginal ultrasound probe, equipped with a specialized needle, will be used to visualize your ovaries. The probe is inserted through the vaginal wall to aspirate fluid from the follicles in the ovaries. After the procedure, you will stay in the recovery room for about an hour, and a responsible adult will need to take you home.<\/p>\r\n<p><\/div><\/p>\r\n<p><b class=\"collapseomatic\" id=\"id69ee4d2a3c99d\"  tabindex=\"0\" title=\"Your Benefits\"    >Your Benefits<\/b><div id=\"target-id69ee4d2a3c99d\" class=\"collapseomatic_content\"><\/p>\r\n<p>All medical costs will be covered, and the egg donor will not be responsible for any out-of-pocket expenses during the screening process or the actual cycle. Travel expenses will also be fully reimbursed. Your participation in the egg donation process is considered a wonderful gift to the intended parents. Depending on your background, compensation typically ranges from $8,000 to $15,000 or higher. The full amount will be remitted to you on the day of egg retrieval.<\/p>\r\n<p><\/div><\/p>\r\n<p><b class=\"collapseomatic\" id=\"id69ee4d2a3c9a8\"  tabindex=\"0\" title=\"Eligibility for Egg Donor\"    >Eligibility for Egg Donor<\/b><div id=\"target-id69ee4d2a3c9a8\" class=\"collapseomatic_content\"><\/p>\r\n<p>The following are the minimum requirements for becoming an egg donor:<\/p>\r\n<ul>\r\n<li>Genuine interest and commitment<\/li>\r\n<li>Age between 19 and 31 years old<\/li>\r\n<li>Non-smoker<\/li>\r\n<li>Normal BMI (Body Mass Index)<\/li>\r\n<li>Ability to provide medical and genetic history<\/li>\r\n<li>Bachelor\u2019s degree or higher (including degrees currently being pursued)<\/li>\r\n<\/ul>\r\n<p>&nbsp;<\/p>\r\n<p>Preferred qualities for an egg donor include:<\/p>\r\n<ul>\r\n<li>Excellent appearance<\/li>\r\n<li>High intelligence with proven achievements in academics or work<\/li>\r\n<li>Strong emotional intelligence<\/li>\r\n<\/ul>\r\n<p><\/div><\/p>\r\n<p><b class=\"collapseomatic\" id=\"id69ee4d2a3c9b2\"  tabindex=\"0\" title=\"How to Apply\"    >How to Apply<\/b><div id=\"target-id69ee4d2a3c9b2\" class=\"collapseomatic_content\"><strong><strong>\u200b<\/strong><\/strong><\/p>\r\n<p>Your first step is to complete the profile under the \"Application\" tab. You will then receive an email notification with a unique Profile Submission ID. Please save this ID for your records.<\/p>\r\n<p>Your application will be reviewed by our egg donor recruiting team and medical directors. Once accepted, our staff will contact you for further information. After all necessary information has been collected, it will be presented to potential recipients anonymously.<\/p>\r\n<p>Once a match is finalized, you will be contacted to begin the screening process and egg donation cycle.<\/p>\r\n<p><\/div><\/p>\r\n<p><b class=\"collapseomatic\" id=\"id69ee4d2a3c9bd\"  tabindex=\"0\" title=\"Application Inquiry\"    >Application Inquiry<\/b><div id=\"target-id69ee4d2a3c9bd\" 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. Our staff will review your request and get back to you as soon as possible.<\/p>\r\n<p><\/div><\/p>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<p><audio style=\"display: none;\" controls=\"controls\"><\/audio><\/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\t\t<div role=\"tabpanel\" class=\"tab-pane animated fadeIn\" id=\"tabs_desc_297_2\">\r\n\t\t\t\t\t<p><div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f91-o1\" lang=\"en\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/zh\/wp-json\/wp\/v2\/pages\/92#wpcf7-f91-o1\" method=\"post\" class=\"wpcf7-form init\" novalidate=\"novalidate\" data-status=\"init\" data-trp-original-action=\"\/zh\/wp-json\/wp\/v2\/pages\/92#wpcf7-f91-o1\">\n<div style=\"display: none;\">\n<input type=\"hidden\" 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equals&quot;,&quot;if_value&quot;:&quot;Unemployed&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-vision-problem&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;vision&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;No&quot;}]},{&quot;then_field&quot;:&quot;group-hearing-problem&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;hearing&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;No&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-growth-hormones-history&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;growth-hormones&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-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-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-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-tubal-pregnancy&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-tubal-pregnancy-times&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;tubal-pregnancy&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-tubal-pregnancy-years&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;tubal-pregnancy&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-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-twins&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;twins&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-not-donate&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;not-donate&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-relation-donated&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;relation-donated&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Other&quot;}]},{&quot;then_field&quot;:&quot;group-idols&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;idols&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;&quot;}]},{&quot;then_field&quot;:&quot;group-travel&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;travel&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;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-children&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;children-number&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;0&quot;},{&quot;if_field&quot;:&quot;children-number&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;&quot;}]},{&quot;then_field&quot;:&quot;group-children-health-issue&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;children-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-mother-sibling&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mother-sibling&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-father-sibling&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;father-sibling&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-mgm-health-issue&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mgm-health-issue&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-mgm-sibling&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mgm-sibling-number&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;0&quot;}]},{&quot;then_field&quot;:&quot;group-mgf-health-issue&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mgf-health-issue&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-mgf-sibling&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mgf-sibling-number&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;0&quot;}]},{&quot;then_field&quot;:&quot;group-pgm-health-issue&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;pgm-health-issue&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-pgm-sibling&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;pgm-sibling-number&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;0&quot;}]},{&quot;then_field&quot;:&quot;group-pgf-health-issue&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;pgf-health-issue&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-pgf-sibling&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;pgf-sibling-number&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;0&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=\"0080388725\" \/>\n<input type=\"hidden\" name=\"generate_name\" value=\"04-26-26-69ee4d2a3fb66\" \/>\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=\"221123999\" 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=\"91\" 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=\"91\" 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<\/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=\"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-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<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=\"adopted\"><select name=\"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><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\">Are you adopted?<\/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\"><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<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=\"hair\"><select name=\"hair\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Black\">Black<\/option><option value=\"Brown\">Brown<\/option><option value=\"Blond\">Blond<\/option><option value=\"Red\">Red<\/option><option value=\"Gray\/White\">Gray\/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\">Hair color<\/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=\"eye\"><select name=\"eye\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Amber\">Amber<\/option><option value=\"Blue\">Blue<\/option><option value=\"Brown\">Brown<\/option><option value=\"Gray\">Gray<\/option><option value=\"Green\">Green<\/option><option value=\"Hazel\">Hazel<\/option><option value=\"Red\">Red<\/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\">Eye color<\/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=\"skin\"><select name=\"skin\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"White\">White<\/option><option value=\"Yellow\">Yellow<\/option><option value=\"Bronze\">Bronze<\/option><option value=\"Dark\">Dark<\/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\">Skin color<\/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=\"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\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-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 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 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 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<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=\"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\">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    \t\t\n\t\t<div class=\"cf7md-item cf7md-text 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 <span class=\"wpcf7-form-control-wrap\" data-name=\"sat-score\"><input type=\"number\" name=\"sat-score\" 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\">score<\/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\">SAT score<\/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-4-desktop mdc-layout-grid__cell--span-3-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"act-score\"><input type=\"number\" name=\"act-score\" 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\">score<\/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\">ACT score<\/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-4-desktop mdc-layout-grid__cell--span-3-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"gre-score\"><input type=\"number\" name=\"gre-score\" 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\">score<\/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\">GRE score<\/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-4-desktop mdc-layout-grid__cell--span-3-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"gmat-score\"><input type=\"number\" name=\"gmat-score\" 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\">score<\/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\">GMAT score<\/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-4-desktop mdc-layout-grid__cell--span-3-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"lsat-score\"><input type=\"number\" name=\"lsat-score\" 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\">score<\/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\">LSAT score<\/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-4-desktop mdc-layout-grid__cell--span-3-tablet mdc-layout-grid__cell--span-4-phone\">\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"gpa\"><input type=\"number\" name=\"gpa\" 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\">score<\/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\">GPA<\/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=\"further-education\"><select name=\"further-education\" 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\">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\">Any plan for further education?<\/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-further-education\" data-orig_data_id=\"group-further-education\"  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=\"plan-for-further-education\"><input type=\"text\" name=\"plan-for-further-education\" 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\">Plan details<\/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=\"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 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\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=\"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\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<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 <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 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<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\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-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=\"vision\"><select name=\"vision\" 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 vision normal (without eyeglasses)?<\/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-vision-problem\" data-orig_data_id=\"group-vision-problem\"  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=\"vision-problem\"><input type=\"text\" name=\"vision-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 explain your vision 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\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=\"hearing\"><select name=\"hearing\" 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 hearing normal?<\/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-hearing-problem\" data-orig_data_id=\"group-hearing-problem\"  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=\"hearing-problem\"><input type=\"text\" name=\"hearing-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 your hearing 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\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=\"teeth\"><select name=\"teeth\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Poor\">Poor<\/option><option value=\"Fair\">Fair<\/option><option value=\"Good\">Good<\/option><option value=\"Excellent\">Excellent<\/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\">Condition of your teeth<\/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-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-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=\"growth-hormones\"><select name=\"growth-hormones\" 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 growth hormones?<\/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-growth-hormones-history\" data-orig_data_id=\"group-growth-hormones-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=\"growth-hormones-history\"><input type=\"text\" name=\"growth-hormones-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\">Growth hormones in the past (including year and 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-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-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 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=\"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=\"first-period-age\"><input type=\"number\" name=\"first-period-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\">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 old were you when you had your first period?<\/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 from one period to the next on average?<\/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-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<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\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-tubal-pregnancy\" data-orig_data_id=\"group-tubal-pregnancy\"  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=\"tubal-pregnancy\"><select name=\"tubal-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 had ectopic tubal pregnancies?<\/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-tubal-pregnancy-times\" data-orig_data_id=\"group-tubal-pregnancy-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=\"tubal-pregnancy-times\"><input type=\"number\" name=\"tubal-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\">Number of ectopic tubal pregnancies<\/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-tubal-pregnancy-years\" data-orig_data_id=\"group-tubal-pregnancy-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=\"tubal-pregnancy-years\"><input type=\"text\" name=\"tubal-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\">Years of those ectopic tubal pregnancies<\/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-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\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?<\/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=\"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\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=\"twins\"><select name=\"twins\" 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 there any identical twins 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-twins\" data-orig_data_id=\"group-twins\"  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=\"twins-details\"><textarea name=\"twins-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\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     \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-donor\"><input type=\"text\" name=\"why-donor\" 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\">Why do you want to be an egg donor?<\/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=\"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 to donate?<\/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-donate\"><select name=\"not-donate\" 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 to whom you will not donate?<\/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-not-donate\" data-orig_data_id=\"group-not-donate\"  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-donate-details\"><textarea name=\"not-donate-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=\"relation-donated\"><select name=\"relation-donated\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Anonymous\">Anonymous<\/option><option value=\"Open (Your contact information will be released)\">Open (Your contact information will be released)<\/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\">What types of relationship with the recipients are you willing to accept?<\/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-relation-donated\" data-orig_data_id=\"group-relation-donated\"  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=\"relation-donated-details\"><textarea name=\"relation-donated-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 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>     \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 <\/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=\"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<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=\"idols\"><input type=\"text\" name=\"idols\" 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 idols<\/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-idols\" data-orig_data_id=\"group-idols\"  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=\"idols-details\"><textarea name=\"idols-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 why you admire them<\/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-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<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=\"travel\"><select name=\"travel\" 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 enjoy traveling?<\/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-travel\" data-orig_data_id=\"group-travel\"  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=\"travel-details\"><input type=\"text\" name=\"travel-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\">flight<\/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 name a few favorite places you have traveled 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\n     <\/div>\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=\"languages-birth\"><input type=\"text\" name=\"languages-birth\" 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 language(s) did you grow up 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\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=\"languages-now\"><input type=\"text\" name=\"languages-now\" 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 language(s) are you speaking?<\/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=\"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<\/p>\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--\">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\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<\/p>\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<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<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\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=\"children-number\"><input type=\"number\" name=\"children-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\">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\">How many children 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-children\" data-orig_data_id=\"group-children\"  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=\"children-health-issue\"><select name=\"children-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-children-health-issue\" data-orig_data_id=\"group-children-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=\"children-health-issue-details\"><textarea name=\"children-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 age 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\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=\"mother-career\"><input type=\"text\" name=\"mother-career\" 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\">Her career 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<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\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-sibling\"><select name=\"mother-sibling\" 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 sibling?<\/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-mother-sibling\" data-orig_data_id=\"group-mother-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-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=\"mother-sibling-number\"><input type=\"number\" name=\"mother-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?<\/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-mother-sibling\" data-orig_data_id=\"group-mother-sibling\"  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-sibling--health-issue\"><textarea name=\"mother-sibling--health-issue\" 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\">Please indicate health or mental issues if any of them has<\/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\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=\"father-career\"><input type=\"text\" name=\"father-career\" 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\">His career 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<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\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-sibling\"><select name=\"father-sibling\" 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 sibling?<\/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-father-sibling\" data-orig_data_id=\"group-father-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-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=\"father-sibling-number\"><input type=\"number\" name=\"father-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?<\/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-father-sibling\" data-orig_data_id=\"group-father-sibling\"  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-sibling-health-issue\"><textarea name=\"father-sibling-health-issue\" 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\">Please indicate health or mental issues if any of them has<\/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=\"mgm-race\"><select name=\"mgm-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\">Maternal grandmother'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=\"mgm-alive\"><select name=\"mgm-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=\"mgm-age\"><input type=\"number\" name=\"mgm-age\" 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 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=\"mgm-blood\"><select name=\"mgm-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=\"mgm-blood-rh\"><select name=\"mgm-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=\"mgm-height\"><input type=\"text\" name=\"mgm-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=\"mgm-weight\"><input type=\"number\" name=\"mgm-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\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=\"mgm-career\"><input type=\"text\" name=\"mgm-career\" 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\">Her career 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<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=\"mgm-health-issue\"><select name=\"mgm-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-mgm-health-issue\" data-orig_data_id=\"group-mgm-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=\"mgm-health-issue-details\"><textarea name=\"mgm-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=\"mgf-race\"><select name=\"mgf-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\">Maternal grandfather'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=\"mgf-alive\"><select name=\"mgf-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=\"mgf-age\"><input type=\"number\" name=\"mgf-age\" 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 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=\"mgf-blood\"><select name=\"mgf-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=\"mgf-blood-rh\"><select name=\"mgf-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=\"mgf-height\"><input type=\"text\" name=\"mgf-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=\"mgf-weight\"><input type=\"number\" name=\"mgf-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\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=\"mgf-career\"><input type=\"text\" name=\"mgf-career\" 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\">His career 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<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=\"mgf-health-issue\"><select name=\"mgf-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-mgf-health-issue\" data-orig_data_id=\"group-mgf-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=\"mgf-health-issue-details\"><textarea name=\"mgf-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=\"pgm-race\"><select name=\"pgm-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\">Paternal grandmother'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=\"pgm-alive\"><select name=\"pgm-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=\"pgm-age\"><input type=\"number\" name=\"pgm-age\" 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 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=\"pgm-blood\"><select name=\"pgm-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=\"pgm-blood-rh\"><select name=\"pgm-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=\"pgm-height\"><input type=\"text\" name=\"pgm-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=\"pgm-weight\"><input type=\"number\" name=\"pgm-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\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=\"pgm-career\"><input type=\"text\" name=\"pgm-career\" 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\">Her career 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<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=\"pgm-health-issue\"><select name=\"pgm-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-pgm-health-issue\" data-orig_data_id=\"group-pgm-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=\"pgm-health-issue-details\"><textarea name=\"pgm-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=\"pgf-race\"><select name=\"pgf-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\">Paternal grandfather'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=\"pgf-alive\"><select name=\"pgf-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=\"pgf-age\"><input type=\"number\" name=\"pgf-age\" 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 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=\"pgf-blood\"><select name=\"pgf-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=\"pgf-blood-rh\"><select name=\"pgf-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=\"pgf-height\"><input type=\"text\" name=\"pgf-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=\"pgf-weight\"><input type=\"number\" name=\"pgf-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\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=\"pgf-career\"><input type=\"text\" name=\"pgf-career\" 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\">His career 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<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=\"pgf-health-issue\"><select name=\"pgf-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-pgf-health-issue\" data-orig_data_id=\"group-pgf-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=\"pgf-health-issue-details\"><textarea name=\"pgf-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--\">Egg Donor 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-239\">Egg Donor 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=\"wpcf7-69ee4d2a45db0-wrapper\" class=\"wpcf7-form-control-wrap website-wrap\" ><label for=\"wpcf7-69ee4d2a45db0-field\" class=\"hp-message\">Please leave this field empty.<\/label><input id=\"wpcf7-69ee4d2a45db0-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>\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\/92"}],"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=92"}],"version-history":[{"count":9,"href":"https:\/\/dawnermedicalservices.com\/zh\/wp-json\/wp\/v2\/pages\/92\/revisions"}],"predecessor-version":[{"id":301,"href":"https:\/\/dawnermedicalservices.com\/zh\/wp-json\/wp\/v2\/pages\/92\/revisions\/301"}],"wp:attachment":[{"href":"https:\/\/dawnermedicalservices.com\/zh\/wp-json\/wp\/v2\/media?parent=92"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}