{"id":1072,"date":"2021-11-03T14:30:26","date_gmt":"2021-11-03T13:30:26","guid":{"rendered":"https:\/\/maxilloriviera.ch\/medecins-referents\/"},"modified":"2023-10-10T14:43:52","modified_gmt":"2023-10-10T12:43:52","slug":"medecins-referents","status":"publish","type":"page","link":"https:\/\/maxilloriviera.ch\/en\/medecins-referents\/","title":{"rendered":"Referring Physicians"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_3' >\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/en\/wp-json\/wp\/v2\/pages\/1072' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_42\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_3_42'><span class='gform-field-label__text'>Date<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='Date'\n\t\t\t\t\tid='input_3_42'\n\t\t\t\t\tclass='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_42'\n\t\t\t\t\tvalue='21\/08\/2026'\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_42' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_42' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_42' aria-label='Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_3_8\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Patient data<\/div><div id=\"field_3_2\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_2'><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_3_2' type='text' value='' class='large'    placeholder='Name *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_3'><span class='gform-field-label__text'>First name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_3_3' type='text' value='' class='large'    placeholder='First name *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_43'><span class='gform-field-label__text'>Date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_3_43' type='text' value='' class='large'    placeholder='jj.mm.yyyy' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_5'><span class='gform-field-label__text'>Parent\/legal representative<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_3_5' type='text' value='' class='large'    placeholder='Name First name (optional)'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_6\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_6'><span class='gform-field-label__text'>E-mail address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_6' id='input_3_6' type='email' value='' class='large'   placeholder='E-mail address *' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_7\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_7'><span class='gform-field-label__text'>Telephone number<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_3_7' type='tel' value='' class='large'  placeholder='Telephone number *' aria-required=\"true\" aria-invalid=\"false\"    \/><\/div><\/div><fieldset id=\"field_3_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Should the patient take antibiotic treatment before surgery?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_9'>\n\t\t\t<div class='gchoice gchoice_3_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Yes'  id='choice_3_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_9_0' id='label_3_9_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='No'  id='choice_3_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_9_1' id='label_3_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Should the patient be called back or will the patient call back?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_10'>\n\t\t\t<div class='gchoice gchoice_3_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='The patient will call to make an appointment'  id='choice_3_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_10_0' id='label_3_10_0' class='gform-field-label gform-field-label--type-inline'>The patient will call to make an appointment<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Please call the patient'  id='choice_3_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_10_1' id='label_3_10_1' class='gform-field-label gform-field-label--type-inline'>Please call the patient<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_12\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><hr>\r\nInformation regarding the referring doctor\r\n<\/div><div id=\"field_3_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_13'><span class='gform-field-label__text'>Referred by<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_3_13' type='text' value='' class='large'    placeholder='Referred by *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_14\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_14'><span class='gform-field-label__text'>E-mail address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_14' id='input_3_14' type='email' value='' class='large'   placeholder='E-mail address *' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_15\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_15'><span class='gform-field-label__text'>Telephone number<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_3_15' type='tel' value='' class='large'  placeholder='Telephone number *' aria-required=\"true\" aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_16\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><hr>\r\nConsultation\r\n<\/div><fieldset id=\"field_3_17\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Consultation<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_17'><div class='gchoice gchoice_3_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='ATM'  id='choice_3_17_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_1' id='label_3_17_1' class='gform-field-label gform-field-label--type-inline'>ATM<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='Cleft lip'  id='choice_3_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_2' id='label_3_17_2' class='gform-field-label gform-field-label--type-inline'>Cleft lip<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.3' type='checkbox'  value='Bone graft'  id='choice_3_17_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_3' id='label_3_17_3' class='gform-field-label gform-field-label--type-inline'>Bone graft<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.4' type='checkbox'  value='Implants'  id='choice_3_17_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_4' id='label_3_17_4' class='gform-field-label gform-field-label--type-inline'>Implants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.5' type='checkbox'  value='Cosmetic'  id='choice_3_17_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_5' id='label_3_17_5' class='gform-field-label gform-field-label--type-inline'>Cosmetic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.6' type='checkbox'  value='3D Radiology (CBCT)'  id='choice_3_17_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_6' id='label_3_17_6' class='gform-field-label gform-field-label--type-inline'>3D Radiology (CBCT)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.7' type='checkbox'  value='Orthognathic Evaluation'  id='choice_3_17_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_7' id='label_3_17_7' class='gform-field-label gform-field-label--type-inline'>Orthognathic Evaluation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.8' type='checkbox'  value='Increased bone volume'  id='choice_3_17_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_8' id='label_3_17_8' class='gform-field-label gform-field-label--type-inline'>Increased bone volume<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.9' type='checkbox'  value='Wisdom teeth'  id='choice_3_17_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_9' id='label_3_17_9' class='gform-field-label gform-field-label--type-inline'>Wisdom teeth<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.11' type='checkbox'  value='Pre-Prosthetic'  id='choice_3_17_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_11' id='label_3_17_11' class='gform-field-label gform-field-label--type-inline'>Pre-Prosthetic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.12' type='checkbox'  value='Oral\/Facial Injury'  id='choice_3_17_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_12' id='label_3_17_12' class='gform-field-label gform-field-label--type-inline'>Oral\/Facial Injury<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_17_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.13' type='checkbox'  value='Other'  id='choice_3_17_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_17_13' id='label_3_17_13' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_19\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>X-rays \/ Clinical Photos<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_19'><div class='gchoice gchoice_3_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Sent by email'  id='choice_3_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_19_1' id='label_3_19_1' class='gform-field-label gform-field-label--type-inline'>Sent by email<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='Given to patient'  id='choice_3_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_19_2' id='label_3_19_2' class='gform-field-label gform-field-label--type-inline'>Given to patient<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_19_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='Please complete the Rx\/photo assessment'  id='choice_3_19_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_19_3' id='label_3_19_3' class='gform-field-label gform-field-label--type-inline'>Please complete the Rx\/photo assessment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_19_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.4' type='checkbox'  value='No x-rays'  id='choice_3_19_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_19_4' id='label_3_19_4' class='gform-field-label gform-field-label--type-inline'>No x-rays<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Implants and surgical guide (optional)<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_23'><div class='gchoice gchoice_3_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Implants'  id='choice_3_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_23_1' id='label_3_23_1' class='gform-field-label gform-field-label--type-inline'>Implants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='Surgical guide'  id='choice_3_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_23_2' id='label_3_23_2' class='gform-field-label gform-field-label--type-inline'>Surgical guide<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_49\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full file-input field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_3_49'><span class='gform-field-label__text'>Radiographies \/ Photos Cliniques<\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_3_49' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_3_49&quot;,&quot;container&quot;:&quot;gform_multifile_upload_3_49&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_3_49&quot;,&quot;filelist&quot;:&quot;gform_preview_3_49&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/maxilloriviera.ch\\\/en\\\/?gf_page=be636bc04955823&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/maxilloriviera.ch\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/maxilloriviera.ch\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;268435456b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:3,&quot;field_id&quot;:49,&quot;_gform_file_upload_nonce_3_49&quot;:&quot;347876ec71&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_3_49&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_3_49' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_3_49' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_3_49\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_3_49'>Max. file size: 256 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_3_49'><\/ul> <div id='gform_preview_3_49' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_3_26\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><hr>\r\nOther interventions\r\n<\/div><fieldset id=\"field_3_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Other interventions (optional)<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_27'><div class='gchoice gchoice_3_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Extraction (see graph)'  id='choice_3_27_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_1' id='label_3_27_1' class='gform-field-label gform-field-label--type-inline'>Extraction (see graph)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='Evaluation of a lesion'  id='choice_3_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_2' id='label_3_27_2' class='gform-field-label gform-field-label--type-inline'>Evaluation of a lesion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_27_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.3' type='checkbox'  value='Alveolar plasty'  id='choice_3_27_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_3' id='label_3_27_3' class='gform-field-label gform-field-label--type-inline'>Alveolar plasty<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_27_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.4' type='checkbox'  value='Discovery of an implant'  id='choice_3_27_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_4' id='label_3_27_4' class='gform-field-label gform-field-label--type-inline'>Discovery of an implant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_27_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.5' type='checkbox'  value='Biopsy'  id='choice_3_27_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_5' id='label_3_27_5' class='gform-field-label gform-field-label--type-inline'>Biopsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_27_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.6' type='checkbox'  value='Infection'  id='choice_3_27_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_6' id='label_3_27_6' class='gform-field-label gform-field-label--type-inline'>Infection<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_27_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.7' type='checkbox'  value='Incision and Drainage of an abscess'  id='choice_3_27_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_7' id='label_3_27_7' class='gform-field-label gform-field-label--type-inline'>Incision and Drainage of an abscess<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_27_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.8' type='checkbox'  value='Frenectomy'  id='choice_3_27_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_8' id='label_3_27_8' class='gform-field-label gform-field-label--type-inline'>Frenectomy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_27_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.9' type='checkbox'  value='Other'  id='choice_3_27_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_9' id='label_3_27_9' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_32\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Extractions (optional)<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_32'><div class='gchoice gchoice_3_32_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.1' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/01-1.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_1' id='label_3_32_1' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/01-1.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.2' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/02.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_2' id='label_3_32_2' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/02.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.3' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/03.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_3' id='label_3_32_3' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/03.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.4' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/04.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_4' id='label_3_32_4' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/04.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.5' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/05.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_5' id='label_3_32_5' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/05.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.6' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/06.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_6' id='label_3_32_6' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/06.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.7' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/07.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_7' id='label_3_32_7' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/07.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.8' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/08.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_8' id='label_3_32_8' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/08.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.9' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/09.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_9' id='label_3_32_9' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/09.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.11' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/10.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_11' id='label_3_32_11' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/10.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.12' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/11.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_12' id='label_3_32_12' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/11.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.13' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/12.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_13' id='label_3_32_13' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/12.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.14' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/13.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_14' id='label_3_32_14' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/13.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.15' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/14.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_15' id='label_3_32_15' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/14.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.16' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/15.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_16' id='label_3_32_16' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/15.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.17' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/16.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_17' id='label_3_32_17' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/16.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.18' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/17.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_18' id='label_3_32_18' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/17.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.19' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/18.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_19' id='label_3_32_19' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/18.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.21' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/19.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_21' id='label_3_32_21' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/19.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.22' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/20.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_22' id='label_3_32_22' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/20.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.23' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/21.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_23' id='label_3_32_23' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/21.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.24' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/22.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_24' id='label_3_32_24' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/22.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.25' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/23.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_25' id='label_3_32_25' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/23.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.26' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/24.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_26' id='label_3_32_26' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/24.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.27' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/25.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_27' id='label_3_32_27' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/25.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.28' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/26.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_28' id='label_3_32_28' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/26.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.29' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/27.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_29' id='label_3_32_29' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/27.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.31' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/28.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_31' id='label_3_32_31' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/28.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.32' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/29.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_32' id='label_3_32_32' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/29.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.33' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/30.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_33' id='label_3_32_33' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/30.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.34' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/31.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_34' id='label_3_32_34' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/31.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.35' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/32.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_32_35'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_35' id='label_3_32_35' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/32.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_44\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Extractions (optional)<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_44'><div class='gchoice gchoice_3_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/a.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_44_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_1' id='label_3_44_1' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/a.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_44_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.2' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/b.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_44_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_2' id='label_3_44_2' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/b.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_44_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.3' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/c.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_44_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_3' id='label_3_44_3' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/c.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_44_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.4' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/d.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_44_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_4' id='label_3_44_4' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/d.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_44_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.5' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/e.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_44_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_5' id='label_3_44_5' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/e.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_44_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.6' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/f.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_44_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_6' id='label_3_44_6' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/f.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_44_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.7' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/g.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_44_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_7' id='label_3_44_7' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/g.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_44_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.8' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/h.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_44_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_8' id='label_3_44_8' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/h.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_44_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.9' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/i.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_44_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_9' id='label_3_44_9' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/i.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_44_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.11' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/j.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_44_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_11' id='label_3_44_11' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/j.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_44_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.12' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/k.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_44_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_12' id='label_3_44_12' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/k.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_44_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.13' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/l.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_44_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_13' id='label_3_44_13' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/l.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_44_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.14' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/m.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_44_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_14' id='label_3_44_14' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/m.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_44_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.15' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/n.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_44_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_15' id='label_3_44_15' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"\/wp-content\/uploads\/2023\/08\/n.png\"><\/img><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_44_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.16' type='checkbox'  value='&lt;img src=&quot;\/wp-content\/uploads\/2023\/08\/o.png&quot;&gt;&lt;\/img&gt;'  id='choice_3_44_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_16' id='label_3_44_16' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" 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