{"id":1698,"date":"2023-12-12T16:42:04","date_gmt":"2023-12-12T08:42:04","guid":{"rendered":"https:\/\/cloone.my\/demo\/ijn2\/?page_id=1698"},"modified":"2023-12-15T11:10:48","modified_gmt":"2023-12-15T03:10:48","slug":"pre-appointment-form","status":"publish","type":"page","link":"https:\/\/cloone.my\/demo\/ijn2\/pre-appointment-form\/","title":{"rendered":"Pre-Appointment Form"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row css_animation=&#8221;&#8221; row_type=&#8221;row&#8221; use_row_as_full_screen_section=&#8221;no&#8221; type=&#8221;grid&#8221; angled_section=&#8221;no&#8221; text_align=&#8221;left&#8221; background_image_as_pattern=&#8221;without_pattern&#8221; css=&#8221;.vc_custom_1702370675153{padding-top: 50px !important;padding-bottom: 20px !important;}&#8221; z_index=&#8221;&#8221;][vc_column width=&#8221;1\/4&#8243;][\/vc_column][vc_column width=&#8221;1\/2&#8243;][vc_column_text]<\/p>\n<h2 style=\"text-align: center;\"><span style=\"color: #004a8f;\">PRE-APPOINTMENT FORM<\/span><\/h2>\n<p>[\/vc_column_text][vc_column_text]Please fill out our Pre-Appointment Form below to book an appointment.[\/vc_column_text][vc_empty_space height=&#8221;20px&#8221;]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1697-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"1697\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/demo\/ijn2\/wp-json\/wp\/v2\/pages\/1698#wpcf7-f1697-o1\" method=\"post\" class=\"wpcf7-form init default cf7mls-auto-return-first-step cf7mls-no-moving-animation\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"1697\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1697-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:1697,&quot;conditions&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,&quot;notice_dismissed_update-cf7-5.9.8&quot;:true}}\" \/>\n<\/div>\n<ul data-id-form=\"1697\" data-bg-color=\"#f78da7\" data-bg-style-bar=\"navigation_horizontal_squaren\" data-style-text=\"vertical\" data-allow-choose-step=\"on\" class=\"cf7mls_progress_bar cf7mls_bar_style_navigation_horizontal_squaren cf7mls_bar_style_text_vertical\" style=\"; \"><li data-counter=\"1\" data-counter_rtl=\"3\" style=\"width: 33.333333333333%\" class=\"cf7_mls_steps_item active current\"><div class=\"cf7_mls_steps_item_container\"><div class=\"cf7_mls_steps_item_icon\"><span class=\"cf7_mls_count_step\">1<\/span><span class=\"cf7_mls_check\"><i><svg viewBox=\"64 64 896 896\" data-icon=\"check\" width=\"14px\" height=\"14px\" fill=\"currentColor\" aria-hidden=\"true\" focusable=\"false\" class=\"\"><path d=\"M912 190h-69.9c-9.8 0-19.1 4.5-25.1 12.2L404.7 724.5 207 474a32 32 0 0 0-25.1-12.2H112c-6.7 0-10.4 7.7-6.3 12.9l273.9 347c12.8 16.2 37.4 16.2 50.3 0l488.4-618.9c4.1-5.1.4-12.8-6.3-12.8z\"><\/path><\/svg><\/i><\/span><span class=\"cf7_mls_invalid\"><i><svg viewBox=\"64 64 896 896\" data-icon=\"close\" width=\"14px\" height=\"14px\" fill=\"currentColor\" aria-hidden=\"true\" focusable=\"false\" class=\"\"><path d=\"M563.8 512l262.5-312.9c4.4-5.2.7-13.1-6.1-13.1h-79.8c-4.7 0-9.2 2.1-12.3 5.7L511.6 449.8 295.1 191.7c-3-3.6-7.5-5.7-12.3-5.7H203c-6.8 0-10.5 7.9-6.1 13.1L459.4 512 196.9 824.9A7.95 7.95 0 00203 838h79.8c4.7 0 9.2-2.1 12.3-5.7l216.5-258.1 216.5 258.1c3 3.6 7.5 5.7 12.3 5.7h79.8c6.8 0 10.5-7.9 6.1-13.1L563.8 512z\"><\/path><\/svg><\/i><\/span><\/div><div class=\"cf7_mls_steps_item_content\"><p class=\"cf7mls_progress_bar_title\">Your Details<\/p><span class=\"cf7_mls_arrow_point_to_righ\"><i><svg x=\"0px\" y=\"0px\" width=\"8px\" height=\"14px\" viewBox=\"0 0 451.846 451.847\" style=\"enable-background:new 0 0 451.846 451.847; xml:space=\"preserve\"><g><path d=\"M345.441,248.292L151.154,442.573c-12.359,12.365-32.397,12.365-44.75,0c-12.354-12.354-12.354-32.391,0-44.744\n                                        L278.318,225.92L106.409,54.017c-12.354-12.359-12.354-32.394,0-44.748c12.354-12.359,32.391-12.359,44.75,0l194.287,194.284\n                                        c6.177,6.18,9.262,14.271,9.262,22.366C354.708,234.018,351.617,242.115,345.441,248.292z\"\/><\/g><\/svg><\/i><\/span><\/div><\/div><\/li><li data-counter=\"2\" data-counter_rtl=\"2\" style=\"width: 33.333333333333%\" class=\"cf7_mls_steps_item \"><div class=\"cf7_mls_steps_item_container\"><div class=\"cf7_mls_steps_item_icon\"><span class=\"cf7_mls_count_step\">2<\/span><span class=\"cf7_mls_check\"><i><svg viewBox=\"64 64 896 896\" data-icon=\"check\" width=\"14px\" height=\"14px\" fill=\"currentColor\" aria-hidden=\"true\" focusable=\"false\" class=\"\"><path d=\"M912 190h-69.9c-9.8 0-19.1 4.5-25.1 12.2L404.7 724.5 207 474a32 32 0 0 0-25.1-12.2H112c-6.7 0-10.4 7.7-6.3 12.9l273.9 347c12.8 16.2 37.4 16.2 50.3 0l488.4-618.9c4.1-5.1.4-12.8-6.3-12.8z\"><\/path><\/svg><\/i><\/span><span class=\"cf7_mls_invalid\"><i><svg viewBox=\"64 64 896 896\" data-icon=\"close\" width=\"14px\" height=\"14px\" fill=\"currentColor\" aria-hidden=\"true\" focusable=\"false\" class=\"\"><path d=\"M563.8 512l262.5-312.9c4.4-5.2.7-13.1-6.1-13.1h-79.8c-4.7 0-9.2 2.1-12.3 5.7L511.6 449.8 295.1 191.7c-3-3.6-7.5-5.7-12.3-5.7H203c-6.8 0-10.5 7.9-6.1 13.1L459.4 512 196.9 824.9A7.95 7.95 0 00203 838h79.8c4.7 0 9.2-2.1 12.3-5.7l216.5-258.1 216.5 258.1c3 3.6 7.5 5.7 12.3 5.7h79.8c6.8 0 10.5-7.9 6.1-13.1L563.8 512z\"><\/path><\/svg><\/i><\/span><\/div><div class=\"cf7_mls_steps_item_content\"><p class=\"cf7mls_progress_bar_title\">Conditions \/ Symptoms<\/p><span class=\"cf7_mls_arrow_point_to_righ\"><i><svg x=\"0px\" y=\"0px\" width=\"8px\" height=\"14px\" viewBox=\"0 0 451.846 451.847\" style=\"enable-background:new 0 0 451.846 451.847; xml:space=\"preserve\"><g><path d=\"M345.441,248.292L151.154,442.573c-12.359,12.365-32.397,12.365-44.75,0c-12.354-12.354-12.354-32.391,0-44.744\n                                        L278.318,225.92L106.409,54.017c-12.354-12.359-12.354-32.394,0-44.748c12.354-12.359,32.391-12.359,44.75,0l194.287,194.284\n                                        c6.177,6.18,9.262,14.271,9.262,22.366C354.708,234.018,351.617,242.115,345.441,248.292z\"\/><\/g><\/svg><\/i><\/span><\/div><\/div><\/li><li data-counter=\"3\" data-counter_rtl=\"1\" style=\"width: 33.333333333333%\" class=\"cf7_mls_steps_item \"><div class=\"cf7_mls_steps_item_container\"><div class=\"cf7_mls_steps_item_icon\"><span class=\"cf7_mls_count_step\">3<\/span><span class=\"cf7_mls_check\"><i><svg viewBox=\"64 64 896 896\" data-icon=\"check\" width=\"14px\" height=\"14px\" fill=\"currentColor\" aria-hidden=\"true\" focusable=\"false\" class=\"\"><path d=\"M912 190h-69.9c-9.8 0-19.1 4.5-25.1 12.2L404.7 724.5 207 474a32 32 0 0 0-25.1-12.2H112c-6.7 0-10.4 7.7-6.3 12.9l273.9 347c12.8 16.2 37.4 16.2 50.3 0l488.4-618.9c4.1-5.1.4-12.8-6.3-12.8z\"><\/path><\/svg><\/i><\/span><span class=\"cf7_mls_invalid\"><i><svg viewBox=\"64 64 896 896\" data-icon=\"close\" width=\"14px\" height=\"14px\" fill=\"currentColor\" aria-hidden=\"true\" focusable=\"false\" class=\"\"><path d=\"M563.8 512l262.5-312.9c4.4-5.2.7-13.1-6.1-13.1h-79.8c-4.7 0-9.2 2.1-12.3 5.7L511.6 449.8 295.1 191.7c-3-3.6-7.5-5.7-12.3-5.7H203c-6.8 0-10.5 7.9-6.1 13.1L459.4 512 196.9 824.9A7.95 7.95 0 00203 838h79.8c4.7 0 9.2-2.1 12.3-5.7l216.5-258.1 216.5 258.1c3 3.6 7.5 5.7 12.3 5.7h79.8c6.8 0 10.5-7.9 6.1-13.1L563.8 512z\"><\/path><\/svg><\/i><\/span><\/div><div class=\"cf7_mls_steps_item_content\"><p class=\"cf7mls_progress_bar_title\">Appointment Details<\/p><span class=\"cf7_mls_arrow_point_to_righ\"><i><svg x=\"0px\" y=\"0px\" width=\"8px\" height=\"14px\" viewBox=\"0 0 451.846 451.847\" style=\"enable-background:new 0 0 451.846 451.847; xml:space=\"preserve\"><g><path d=\"M345.441,248.292L151.154,442.573c-12.359,12.365-32.397,12.365-44.75,0c-12.354-12.354-12.354-32.391,0-44.744\n                                        L278.318,225.92L106.409,54.017c-12.354-12.359-12.354-32.394,0-44.748c12.354-12.359,32.391-12.359,44.75,0l194.287,194.284\n                                        c6.177,6.18,9.262,14.271,9.262,22.366C354.708,234.018,351.617,242.115,345.441,248.292z\"\/><\/g><\/svg><\/i><\/span><\/div><\/div><\/li><\/ul><div class=\"cf7mls_number_step_wrap\" data-bg-color=\"#f78da7\" data-number-step=\"3\"><p class=\"cf7mls_number\">1\/3<\/p><p class=\"cf7mls_step_current\">Your Details<\/p><div class=\"cf7mls_progress_percent\"><div class=\"cf7mls_progress_bar_percent\"><div class=\"cf7mls_progress_barinner\"><\/div><\/div><\/div><\/div><div class=\"fieldset-cf7mls-wrapper\" data-transition-effects=\"in_fadeInUp next_fadeInUp back_fadeInUp\"><fieldset class=\"fieldset-cf7mls cf7mls_current_fs\"><p><label> Patient Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Patient Name\" value=\"\" type=\"text\" name=\"patient-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Gender<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"gender\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"gender\" value=\"Male\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"gender\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><\/span><\/span> <\/label>\n<\/p>\n<p><label> Date of Birth<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dob\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"dob\" \/><\/span> <\/label>\n<\/p>\n<p><label> NRIC \/ Passport<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nric-passport\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"NRIC \/ Passport\" value=\"\" type=\"text\" name=\"nric-passport\" \/><\/span> <\/label>\n<\/p>\n<p><label> Nationality<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nationality\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nationality\" value=\"\" type=\"text\" name=\"nationality\" \/><\/span> <\/label>\n<\/p>\n<p><label> Contact Number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"contact-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Contact Number\" value=\"\" type=\"text\" name=\"contact-number\" \/><\/span> <\/label>\n<\/p>\n<p><label> Email<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span> <\/label>\n<\/p>\n<p><label> Address<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><textarea cols=\"40\" rows=\"3\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Address\" name=\"address\"><\/textarea><\/span> <\/label>\n<\/p>\n<div class=\"cf7mls-btns\"><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-1\">Next<img decoding=\"async\" src=\"https:\/\/cloone.my\/demo\/ijn2\/wp-content\/plugins\/ninjateam-cf7-multi-step-pro\/assets\/frontend\/img\/loader.svg\" alt=\"\" data-lazy-src=\"https:\/\/cloone.my\/demo\/ijn2\/wp-content\/plugins\/ninjateam-cf7-multi-step-pro\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\" \/><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\"><label> Patient's current medical conditions \/ symptoms \/ diagnosis (if any)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"conditions-symptoms\"><textarea cols=\"40\" rows=\"5\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Patient&#039;s current medical conditions \/ symptoms \/ diagnosis (if any)\" name=\"conditions-symptoms\"><\/textarea><\/span><\/label>\n<\/p>\n<p><label> Upload any relevant document<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"document\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"document\" \/><\/span><\/label><div class=\"cf7mls-btns\"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-2\">Back<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-2\">Next<img decoding=\"async\" src=\"https:\/\/cloone.my\/demo\/ijn2\/wp-content\/plugins\/ninjateam-cf7-multi-step-pro\/assets\/frontend\/img\/loader.svg\" alt=\"\" data-lazy-src=\"https:\/\/cloone.my\/demo\/ijn2\/wp-content\/plugins\/ninjateam-cf7-multi-step-pro\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\" \/><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\"><label> Are You Referred By A Doctor<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"refer\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"refer\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"refer\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/label>\n<\/p>\n<p><label> Preferred Appointment Date<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"appointment-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"appointment-date\" \/><\/span><\/label>\n<\/p>\n<p><label> Preferred Time slot<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"timeslot\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"timeslot\" \/><\/span><\/label>\n<\/p>\n<p><label> Preferred Specialist<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"preferred-specialist\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"preferred-specialist\" value=\"Cardiologist\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Cardiologist<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"preferred-specialist\" value=\"Cardiothoracic Surgeons\" \/><span class=\"wpcf7-list-item-label\">Cardiothoracic Surgeons<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"preferred-specialist\" value=\"Consultant Nephrologist\" \/><span class=\"wpcf7-list-item-label\">Consultant Nephrologist<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"preferred-specialist\" value=\"Vascular Surgeon\" \/><span class=\"wpcf7-list-item-label\">Vascular Surgeon<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"preferred-specialist\" value=\"Paediatric Cardiology\" \/><span class=\"wpcf7-list-item-label\">Paediatric Cardiology<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"preferred-specialist\" value=\"Consultant Pulmonologist\" \/><span class=\"wpcf7-list-item-label\">Consultant Pulmonologist<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"preferred-specialist\" value=\"Endocrinologist\" \/><span class=\"wpcf7-list-item-label\">Endocrinologist<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"preferred-specialist\" value=\"Not Sure\" \/><span class=\"wpcf7-list-item-label\">Not Sure<\/span><\/label><\/span><\/span><\/span><\/label>\n<\/p>\n<p><label> Do you need airport transport?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"airport-transfer\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"airport-transfer\" value=\"Yes (Fees apply)\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes (Fees apply)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"airport-transfer\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/label>\n<\/p>\n<p><label> Payment Method<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"payment\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"payment\" value=\"Self Pay\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Self Pay<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"payment\" value=\"Government\" \/><span class=\"wpcf7-list-item-label\">Government<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"payment\" value=\"Insurance\" \/><span class=\"wpcf7-list-item-label\">Insurance<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"payment\" value=\"Other methods\" \/><span class=\"wpcf7-list-item-label\">Other methods<\/span><\/label><\/span><\/span><\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Other methods, please specify\" value=\"\" type=\"text\" name=\"other\" \/><\/span>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-3\">Back<\/button><button type=\"button\" style=\"display: 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