{"id":1989,"date":"2022-05-17T09:04:26","date_gmt":"2022-05-17T07:04:26","guid":{"rendered":"https:\/\/www.eyemark.co.za\/demos\/comprehensive\/?page_id=1989"},"modified":"2022-07-05T13:11:25","modified_gmt":"2022-07-05T11:11:25","slug":"patient-information","status":"publish","type":"page","link":"https:\/\/www.eyemark.co.za\/demos\/comprehensive\/patient-information\/","title":{"rendered":"Patient Information"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1989\" class=\"elementor elementor-1989\">\n\t\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-fc8d11a elementor-section-full_width elementor-section-height-min-height elementor-section-stretched elementor-section-height-default elementor-section-items-middle\" data-id=\"fc8d11a\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-52bdc52\" data-id=\"52bdc52\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-9c414a6 elementor-widget elementor-widget-heading\" data-id=\"9c414a6\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.15.0 - 20-08-2023 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h2 class=\"elementor-heading-title elementor-size-default\">Patient Information<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-0236538 elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"0236538\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-eea18d6\" data-id=\"eea18d6\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-d527b47 elementor-widget elementor-widget-spacer\" data-id=\"d527b47\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.15.0 - 20-08-2023 *\/\n.elementor-column .elementor-spacer-inner{height:var(--spacer-size)}.e-con{--container-widget-width:100%}.e-con-inner>.elementor-widget-spacer,.e-con>.elementor-widget-spacer{width:var(--container-widget-width,var(--spacer-size));--align-self:var(--container-widget-align-self,initial);--flex-shrink:0}.e-con-inner>.elementor-widget-spacer>.elementor-widget-container,.e-con-inner>.elementor-widget-spacer>.elementor-widget-container>.elementor-spacer,.e-con>.elementor-widget-spacer>.elementor-widget-container,.e-con>.elementor-widget-spacer>.elementor-widget-container>.elementor-spacer{height:100%}.e-con-inner>.elementor-widget-spacer>.elementor-widget-container>.elementor-spacer>.elementor-spacer-inner,.e-con>.elementor-widget-spacer>.elementor-widget-container>.elementor-spacer>.elementor-spacer-inner{height:var(--container-widget-height,var(--spacer-size))}<\/style>\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-7f3cd83 elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"7f3cd83\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-99a5ab2\" data-id=\"99a5ab2\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-c0408ca elementor-widget elementor-widget-text-editor\" data-id=\"c0408ca\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.15.0 - 20-08-2023 *\/\n.elementor-widget-text-editor.elementor-drop-cap-view-stacked .elementor-drop-cap{background-color:#69727d;color:#fff}.elementor-widget-text-editor.elementor-drop-cap-view-framed .elementor-drop-cap{color:#69727d;border:3px solid;background-color:transparent}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap{margin-top:8px}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap-letter{width:1em;height:1em}.elementor-widget-text-editor .elementor-drop-cap{float:left;text-align:center;line-height:1;font-size:50px}.elementor-widget-text-editor .elementor-drop-cap-letter{display:inline-block}<\/style>\t\t\t\t<p style=\"margin-bottom:0px;\">To speed up the administration process when you arrive at the practice, please complete and submit this form.<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-4011e49 elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"4011e49\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-fa0f2d8\" data-id=\"fa0f2d8\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-37cae51 elementor-widget elementor-widget-spacer\" data-id=\"37cae51\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-735ab38a elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"735ab38a\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-4da2a480\" data-id=\"4da2a480\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-af44749 elementor-widget elementor-widget-shortcode\" data-id=\"af44749\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"cf7sg-container\"><div id=\"cf7sg-form-patient-information\" class=\"cf7-smart-grid has-grid key_patient-information\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2036-o1\" lang=\"en-ZA\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/demos\/comprehensive\/wp-json\/wp\/v2\/pages\/1989#wpcf7-f2036-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"2036\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.8\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_ZA\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2036-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=\"_wpcf7_key\" value=\"patient-information\" \/>\n<input type=\"hidden\" name=\"_cf7sg_toggles\" value=\"\" \/>\n<input type=\"hidden\" name=\"_cf7sg_version\" value=\"4.15.4\" \/>\n<input type=\"hidden\" name=\"_wpnonce\" value=\"721f87436a\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div class=\"container\">\n  <div class=\"row\">\n    <div class=\"columns full\">\n      <h4>Patient Details<\/h4>\n    <\/div>\n  <\/div>\n<\/div>\n<div class=\"container\">\n  <div class=\"row\">\n    <div class=\"columns two\">\n      <div class=\"field select required\"><label>Title <em>*<\/em><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"patient-title\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"patient-title\"><option value=\"Select\">Select<\/option><option value=\"Mr.\">Mr.<\/option><option value=\"Mrs.\">Mrs.<\/option><option value=\"Ms.\">Ms.<\/option><option value=\"Dr.\">Dr.<\/option><option value=\"Prof.\">Prof.<\/option><option value=\"Other\">Other<\/option><\/select><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n    <div class=\"columns five\">\n      <div class=\"field text required\"><label>First Name <em>*<\/em><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"patient-firstname\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-firstname\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n    <div class=\"columns five\">\n      <div class=\"field text required\"><label>Surname <em>*<\/em><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"patient-surname\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-surname\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n  <\/div>\n<\/div>\n<div class=\"container\">\n  <div class=\"row\">\n    <div class=\"columns one-fourth\">\n      <div class=\"field text required\"><label>Telephone <em>*<\/em><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"patient-telephone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-telephone\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n    <div class=\"columns one-fourth\">\n      <div class=\"field text required\"><label>Cellphone <em>*<\/em><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"patient-cellphone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-cellphone\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n    <div class=\"columns one-half\">\n      <div class=\"field email required\"><label>Email <em>*<\/em><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"patient-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"patient-email\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n  <\/div>\n<\/div>\n<div class=\"container\">\n  <div class=\"row\">\n    <div class=\"columns one-fourth\">\n      <div class=\"field text required\"><label>ID Number <em>*<\/em><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"patient-id\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-id\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n    <div class=\"columns one-fourth\">\n      <div class=\"field text required\"><label>Date of Birth <em>*<\/em><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"patient-dob\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-dob\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n  <\/div>\n<\/div>\n<div class=\"container\">\n  <div class=\"row\">\n    <div align=\"center\" class=\"columns full\">\n      <hr style=\"width:75%;margin: 1em 0;background-color:#eeeeee\">\n    <\/div>\n  <\/div>\n<\/div>\n<div class=\"container\">\n  <div class=\"row\">\n    <div class=\"columns full\">\n      <h4>Person Responsible for Your Account<\/h4>\n    <\/div>\n  <\/div>\n<\/div>\n<div class=\"container\">\n  <div class=\"row\">\n    <div class=\"columns two\">\n      <div class=\"field select required\"><label>Title<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"account-title\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"account-title\"><option value=\"Select\">Select<\/option><option value=\"Mr.\">Mr.<\/option><option value=\"Mrs.\">Mrs.<\/option><option value=\"Ms.\">Ms.<\/option><option value=\"Dr.\">Dr.<\/option><option value=\"Prof.\">Prof.<\/option><option value=\"Other\">Other<\/option><\/select><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n    <div class=\"columns five\">\n      <div class=\"field text required\"><label>First Name<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"account-firstname\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"account-firstname\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n    <div class=\"columns five\">\n      <div class=\"field text required\"><label>Surname<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"account-surname\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"account-surname\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n  <\/div>\n<\/div>\n<div class=\"container\">\n  <div class=\"row\">\n    <div class=\"columns one-fourth\">\n      <div class=\"field text required\"><label>Telephone<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"account-telephone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"account-telephone\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n    <div class=\"columns one-fourth\">\n      <div class=\"field text required\"><label>Cellphone<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"account-cellphone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"account-cellphone\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n    <div class=\"columns one-half\">\n      <div class=\"field email required\"><label>Email<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"account-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"account-email\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n  <\/div>\n<\/div>\n<div class=\"container\">\n  <div class=\"row\">\n    <div class=\"columns one-fourth\">\n      <div class=\"field text required\"><label>ID Number<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"account-id\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"account-id\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n  <\/div>\n<\/div>\n<div class=\"container\">\n  <div class=\"row\">\n    <div align=\"center\" class=\"columns full\">\n      <hr style=\"width:75%;margin: 1em 0;background-color:#eeeeee\">\n    <\/div>\n  <\/div>\n<\/div>\n<div class=\"container\">\n  <div class=\"row\">\n    <div class=\"columns full\">\n      <h4>Medical Aid<\/h4>\n    <\/div>\n  <\/div>\n<\/div>\n<div class=\"container\">\n  <div class=\"row\">\n    <div class=\"columns one-fourth\">\n      <div class=\"field text required\"><label>Medical Aid<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"medical-aid-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"medical-aid-name\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n    <div class=\"columns one-fourth\">\n      <div class=\"field text required\"><label>Plan<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"medical-aid-plan\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"medical-aid-plan\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n    <div class=\"columns one-fourth\">\n      <div class=\"field text required\"><label>Number<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"medical-aid-number\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"medical-aid-number\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n    <div class=\"columns one-fourth\">\n      <div class=\"field text required\"><label>Member Name<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"medical-aid-member\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"medical-aid-member\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n  <\/div>\n<\/div>\n<div class=\"container\">\n  <div class=\"row\">\n    <div align=\"center\" class=\"columns full\">\n      <hr style=\"width:75%;margin: 1em 0;background-color:#eeeeee\">\n    <\/div>\n  <\/div>\n<\/div>\n<div class=\"container\">\n  <div class=\"row\">\n    <div class=\"columns full\">\n      <h4>Nearest Family or Friend<\/h4>\n    <\/div>\n  <\/div>\n<\/div>\n<div class=\"container\">\n  <div class=\"row\">\n    <div class=\"columns one-fourth\">\n      <div class=\"field text required\"><label>Name <em>*<\/em><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"family-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"family-name\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n    <div class=\"columns one-fourth\">\n      <div class=\"field text required\"><label>Relation <em>*<\/em><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"family-relation\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"family-relation\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n    <div class=\"columns one-fourth\">\n      <div class=\"field text required\"><label>Cellphone <em>*<\/em><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"family-cellphone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"family-cellphone\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n    <div class=\"columns one-fourth\">\n      <div class=\"field text required\"><label>Telephone <em>*<\/em><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"family-telephone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"family-telephone\" \/><\/span>\n        <p class=\"info-tip\"><\/p>\n      <\/div>\n    <\/div>\n  <\/div>\n<\/div>\n<div class=\"container\">\n  <div class=\"row\">\n    <div align=\"center\" class=\"columns full\">\n      <hr style=\"width:75%;margin: 1em 0;background-color:#eeeeee\">\n    <\/div>\n  <\/div>\n<\/div>\n<div class=\"container\">\n  <div class=\"row\">\n    <div class=\"columns full\">\n      <div class=\"field 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