{"id":2861,"date":"2026-05-13T14:13:22","date_gmt":"2026-05-13T12:13:22","guid":{"rendered":"https:\/\/rive-droite.quavitae.ch\/form\/"},"modified":"2026-05-27T12:15:39","modified_gmt":"2026-05-27T10:15:39","slug":"form","status":"publish","type":"page","link":"https:\/\/rive-droite.quavitae.ch\/en\/form\/","title":{"rendered":"Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2861\" class=\"elementor elementor-2861 elementor-2828\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0d33488 e-flex e-con-boxed e-con e-parent\" data-id=\"0d33488\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0e75757 elementor-widget elementor-widget-text-editor\" data-id=\"0e75757\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<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 gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital qrd-dialyse-form_wrapper' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_2' style='display:none'><style>#gform_wrapper_2[data-form-index=\"0\"].gform-theme,[data-parent-form=\"2_0\"]{--gf-color-primary: 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Holiday dialysis request<\/h2>\n                            <p class='gform_description'>Please complete this form to prepare your dialysis care. <br>We will get back to you shortly after receipt.<\/p>\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_2' class='qrd-dialyse-form' action='\/en\/wp-json\/wp\/v2\/pages\/2861#gf_2' data-formid='2' novalidate>\n        <div id='gf_progressbar_wrapper_2' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>5<\/span><span class='gf_step_page_name'> &#8211; Identity<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_20' style='width:20%;'><span>20%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_2_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_2_76\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_76'>Phone<\/label><div class='ginput_container'><input name='input_76' id='input_2_76' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_2_76'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_2_1\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Patient information<\/h3><\/div><fieldset id=\"field_2_2\" class=\"gfield gfield--type-name gfield--input-type-name qrd-hide-main-label gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Full name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_2'>\n                            \n                            <span id='input_2_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_2_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_2.3' id='input_2_2_3' value=''   aria-required='true'   placeholder='E.g.: Marie'  \/>\n                                                <\/span>\n                            \n                            <span id='input_2_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_2_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_2.6' id='input_2_2_6' value=''   aria-required='true'   placeholder='E.g.: Dupont'  \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_3'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_2_3' type='text' value='' class='datepicker gform-datepicker dmy_dot datepicker_with_icon gdatepicker_with_icon'   placeholder='DD.MM.YYYY' aria-describedby=\"input_2_3_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_3_date_format' class='screen-reader-text'>DD dot MM dot YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_3' class='gform_hidden' value='https:\/\/rive-droite.quavitae.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_4\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_4'>Email<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_4' id='input_2_4' type='email' value='' class='medium'   placeholder='E.g.: marie.dupont@exemple.ch' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_5\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_5'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_2_5' type='tel' value='' class='medium'  placeholder='E.g.: +41 79 123 45 67' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_6\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_6'>Emergency contact phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_2_6' type='tel' value='' class='medium'  placeholder='E.g.: +41 22 123 45 67' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_7\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Home address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_2_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_7_1_container' >\n                                        <label for='input_2_7_1' id='input_2_7_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_7.1' id='input_2_7_1' value=''   placeholder='E.g.: 12 Rue de la Paix' aria-required='true'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_2_7_2_container' >\n                                        <label for='input_2_7_2' id='input_2_7_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_7.2' id='input_2_7_2' value=''   placeholder='Apartment, floor\u2026'  aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_7_3_container' >\n                                    <label for='input_2_7_3' id='input_2_7_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_7.3' id='input_2_7_3' value=''   placeholder='E.g.: Geneva' aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_7_4_container' >\n                                        <label for='input_2_7_4' id='input_2_7_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                        <input type='text' name='input_7.4' id='input_2_7_4' value=''      aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_7_5_container' >\n                                    <label for='input_2_7_5' id='input_2_7_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_7.5' id='input_2_7_5' value=''   placeholder='E.g.: 1209' aria-required='true'    \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_2_7_6_container' >\n                                        <label for='input_2_7_6' id='input_2_7_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                        <select name='input_7.6' id='input_2_7_6'   aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option> <\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_2_8' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_2_2_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and forward<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_2' class='gform_page' data-js='page-field-id-8' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_2' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_2_9\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Requested dialysis sessions<\/h3><\/div><div id=\"field_2_10\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_10'>Requested arrival date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_10' id='input_2_10' type='text' value='' class='datepicker gform-datepicker dmy_dot datepicker_with_icon gdatepicker_with_icon'   placeholder='DD.MM.YYYY' aria-describedby=\"input_2_10_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_10_date_format' class='screen-reader-text'>DD dot MM dot YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_10' class='gform_hidden' value='https:\/\/rive-droite.quavitae.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_11\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_11'>Requested departure date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_11' id='input_2_11' type='text' value='' class='datepicker gform-datepicker dmy_dot datepicker_with_icon gdatepicker_with_icon'   placeholder='DD.MM.YYYY' aria-describedby=\"input_2_11_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_11_date_format' class='screen-reader-text'>DD dot MM dot YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_11' class='gform_hidden' value='https:\/\/rive-droite.quavitae.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_2_12\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Preferred days<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_2_12'><div class='gchoice gchoice_2_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='monday'  id='choice_2_12_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_1' id='label_2_12_1' class='gform-field-label gform-field-label--type-inline'>Monday<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='tuesday'  id='choice_2_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_2' id='label_2_12_2' class='gform-field-label gform-field-label--type-inline'>Tuesday<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='wednesday'  id='choice_2_12_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_3' id='label_2_12_3' class='gform-field-label gform-field-label--type-inline'>Wednesday<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_12_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.4' type='checkbox'  value='thursday'  id='choice_2_12_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_4' id='label_2_12_4' class='gform-field-label gform-field-label--type-inline'>Thursday<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_12_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.5' type='checkbox'  value='friday'  id='choice_2_12_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_5' id='label_2_12_5' class='gform-field-label gform-field-label--type-inline'>Friday<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_12_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.6' type='checkbox'  value='saturday'  id='choice_2_12_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_6' id='label_2_12_6' class='gform-field-label gform-field-label--type-inline'>Saturday<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Preferred time<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_2_13'>\n\t\t\t<div class='gchoice gchoice_2_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='morning'  id='choice_2_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_13_0' id='label_2_13_0' class='gform-field-label gform-field-label--type-inline'>Morning<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='afternoon'  id='choice_2_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_13_1' id='label_2_13_1' class='gform-field-label gform-field-label--type-inline'>Afternoon<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_14\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_14'>Holiday address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_2_14' class='textarea medium'    placeholder='Full address at your holiday location' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_15\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_15'>Address of your usual dialysis center<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_15' id='input_2_15' class='textarea medium'    placeholder='Name and full address' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_16\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_16'>Phone number of your usual center<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_2_16' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_17\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_17'>Email of your usual center<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_17' id='input_2_17' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_18' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_2_18' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_2_3_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and forward<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_3' class='gform_page' data-js='page-field-id-18' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_3' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_2_19\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Diagnoses and medical history<\/h3><\/div><div id=\"field_2_20\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_20'>Diagnoses and medical history<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_20' id='input_2_20' class='textarea medium'    placeholder='Describe conditions, ongoing treatments, past procedures\u2026' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_21\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_21'>Allergies<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_2_21' type='text' value='' class='medium'    placeholder='E.g.: penicillin, latex\u2026'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_22\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_22'>On dialysis since<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_2_22' type='text' value='' class='medium'    placeholder='E.g.: March 2019' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Listed for transplant<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_2_23'>\n\t\t\t<div class='gchoice gchoice_2_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='yes'  id='choice_2_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_23_0' id='label_2_23_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_2_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='no'  id='choice_2_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_23_1' id='label_2_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_24' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_2_24' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_2_4_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and forward<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_4' class='gform_page' data-js='page-field-id-24' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_4' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_2_25\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"qrd-info-card\">\n  <h2>Section to be completed by your usual dialysis center<\/h2>\n  <p>The information below (dialysis modality, vascular access, anticoagulation, technical parameters) comes from the patient\u2019s current Dialysis protocol. It must be completed by your usual dialysis center \u2014 physician, specialist nurse, or administrative staff with the up-to-date protocol. <\/p>\n  <ul>\n    <li><strong>Are you the patient and do not have this information to hand?<\/strong> Click <em>\u201cSave and forward\u201d<\/em> at the bottom of the page and enter the email address of your usual dialysis center. They will receive a unique link to complete this section, then send it back to you so you can attach your documents (page 5) and submit the request to the center. <\/li>\n    <li><strong>Are you the dialysis center?<\/strong> Complete the section below, then click <em>\u201cSave and forward\u201d<\/em> and enter the patient\u2019s email address. They will then be able to finalize the request by attaching the required documents and submitting it. <\/li>\n  <\/ul>\n<\/div><\/div><div id=\"field_2_26\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Dialysis protocol \u2014 General parameters<\/h3><\/div><fieldset id=\"field_2_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Dialysis modality<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_2_27'>\n\t\t\t<div class='gchoice gchoice_2_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='hdf'  id='choice_2_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_27_0' id='label_2_27_0' class='gform-field-label gform-field-label--type-inline'>HDF<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='hd'  id='choice_2_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_27_1' id='label_2_27_1' class='gform-field-label gform-field-label--type-inline'>HD<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_28'>Treatment duration<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_2_28' type='text' value='' class='medium'    placeholder='E.g.: 4 h' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Vascular access<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_2_29'>\n\t\t\t<div class='gchoice gchoice_2_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='fistula'  id='choice_2_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_29_0' id='label_2_29_0' class='gform-field-label gform-field-label--type-inline'>Fistula<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='catheter'  id='choice_2_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_29_1' id='label_2_29_1' class='gform-field-label gform-field-label--type-inline'>Catheter<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_29_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='single_needle'  id='choice_2_29_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_29_2' id='label_2_29_2' class='gform-field-label gform-field-label--type-inline'>Single-needle<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_30\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_30'>Catheter \u2014 A (ml)<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_2_30' type='text' value='' class='medium'    placeholder='ml'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_31\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_31'>Catheter \u2014 V (ml)<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_2_31' type='text' value='' class='medium'    placeholder='ml'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_32\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_32'>Lock solution<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_2_32' type='text' value='' class='medium'    placeholder='E.g.: 4% citrate'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_33'>Location<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_2_33' type='text' value='' class='medium'    placeholder='E.g.: left forearm' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_34\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_34'>Needles<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_2_34' type='text' value='' class='medium'    placeholder='E.g.: 15G' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_35'>Blood flow rate<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_2_35' type='text' value='' class='medium'    placeholder='ml\/min' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_36'>Dry weight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_2_36' type='text' value='' class='medium'    placeholder='kg' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_37'>Max UF rate<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_2_37' type='text' value='' class='medium'    placeholder='ml\/h' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_38\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_38'>Filter \/ Dialyzer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_2_38' type='text' value='' class='medium'    placeholder='E.g.: Polyflux 21L' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_39\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_39'>Notes (protocol)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_39' id='input_2_39' class='textarea medium'    placeholder='Additional notes'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_40\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Dialysate composition<\/h3><\/div><div id=\"field_2_41\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_41'>Bicarbonate (mmol\/l)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_41' id='input_2_41' type='number' step='any'   value='' class='medium'    placeholder='E.g.: 32' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_42\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_42'>K (mmol\/l)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_42' id='input_2_42' type='number' step='any'   value='' class='medium'    placeholder='E.g.: 2' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_2_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Calcium (mmol\/l)<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_2_43'>\n\t\t\t<div class='gchoice gchoice_2_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='1.25'  id='choice_2_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_43_0' id='label_2_43_0' class='gform-field-label gform-field-label--type-inline'>1.25<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='1.5'  id='choice_2_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_43_1' id='label_2_43_1' class='gform-field-label gform-field-label--type-inline'>1.5<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_44\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_44'>Glucose (mmol\/l)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_44' id='input_2_44' type='number' step='any'   value='' class='medium'    placeholder='E.g.: 1' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_45\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_45'>Na (mmol\/l)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_45' id='input_2_45' type='number' step='any'   value='' class='medium'    placeholder='E.g.: 138' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_46\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Anticoagulation<\/h3><\/div><div id=\"field_2_47\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_47'>Heparin (type)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_2_47' type='text' value='' class='medium'    placeholder='E.g.: Unfractionated heparin' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_48\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_48'>Heparin \u2014 initial dose (IU)<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_2_48' type='text' value='' class='medium'    placeholder='IU'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_49\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_49'>Heparin \u2014 continuous dose (IU\/h)<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_2_49' type='text' value='' class='medium'    placeholder='IU\/h'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_50\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_50'>Initial LMWH<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_2_50' type='text' value='' class='medium'    placeholder='E.g.: Enoxaparin 40 mg'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_51\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Blood pressure<\/h3><\/div><div id=\"field_2_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_52'>Blood pressure \u2014 before dialysis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_2_52' type='text' value='' class='medium'    placeholder='E.g.: 130\/80' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_53\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_53'>Blood pressure \u2014 after dialysis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_2_53' type='text' value='' class='medium'    placeholder='E.g.: 120\/75' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_54\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Additional information<\/h3><\/div><div id=\"field_2_55\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_55'>Complications during the session<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_55' id='input_2_55' class='textarea medium'    placeholder='E.g.: cramps, hypotension\u2026'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_56\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_56'>General notes<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_56' id='input_2_56' class='textarea medium'    placeholder='Any useful information'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_57'>Spoken language<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_2_57' type='text' value='' class='medium'    placeholder='E.g.: French, English' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_58\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_58'>Mobility<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_2_58' type='text' value='' class='medium'    placeholder='E.g.: independent \/ with assistance \/ wheelchair'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_59\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_59'>Diet<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_2_59' type='text' value='' class='medium'    placeholder='E.g.: low-salt, no pork, diabetic\u2026'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_70\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Medical validation<\/h3><\/div><div id=\"field_2_71\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_71'>Document completed on<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_71' id='input_2_71' type='text' value='' class='datepicker gform-datepicker dmy_dot datepicker_with_icon gdatepicker_with_icon'   placeholder='DD.MM.YYYY' aria-describedby=\"input_2_71_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_71_date_format' class='screen-reader-text'>DD dot MM dot YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_71' class='gform_hidden' value='https:\/\/rive-droite.quavitae.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_72\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_72'>Place (at)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_2_72' type='text' value='' class='medium'    placeholder='E.g.: Lyon' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_73\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_73'>Name of signing physician<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_2_73' type='text' value='' class='medium'    placeholder='E.g.: Dr Jean Martin' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_74\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_74'>Dialysis center \/ Hospital \/ Practice<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_2_74' type='text' value='' class='medium'    placeholder='E.g.: Lyon Sud Dialysis Center' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_75\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_75'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_75' id='input_2_75_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_2_75_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_2_75' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/rive-droite.quavitae.ch\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_2_75_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_2_75_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_2_75_data' name='input_2_75_data' value=''><\/div><div class='gfield_description' id='gfield_description_2_75'>Draw your signature with your finger (mobile) or mouse (computer).<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_60' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_2_60' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_2_5_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and forward<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_5' class='gform_page' data-js='page-field-id-60' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_5' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_2_61\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p style=\"font-size:14px;line-height:1.5;\">Please attach the following documents in <strong>PDF, JPG, or PNG<\/strong> format (max size: 10 MB per file).<\/p><\/div><div id=\"field_2_62\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Attachments<\/h3><\/div><div id=\"field_2_63\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_63'>Latest lab results<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_63'>Recent blood tests (< 3 months).<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_63' id='input_2_63' type='file' class='medium' aria-describedby=\"gfield_upload_rules_2_63 gfield_description_2_63\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_2_63'>Accepted file types: pdf, jpg, jpeg, png, heic, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_2_63'><\/div> <\/div><\/div><div id=\"field_2_64\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_64'>Serologies Hep B, Hep C, HIV<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_64'>Up-to-date serology results.<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_64' id='input_2_64' type='file' class='medium' aria-describedby=\"gfield_upload_rules_2_64 gfield_description_2_64\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_2_64'>Accepted file types: pdf, jpg, jpeg, png, heic, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_2_64'><\/div> <\/div><\/div><div id=\"field_2_65\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_65'>Medication list<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_65'>Prescription or detailed list of current treatments.<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_65' id='input_2_65' type='file' class='medium' aria-describedby=\"gfield_upload_rules_2_65 gfield_description_2_65\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_2_65'>Accepted file types: pdf, jpg, jpeg, png, heic, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_2_65'><\/div> <\/div><\/div><div id=\"field_2_66\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_66'>ID card or passport<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_66'>Valid ID document.<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_66' id='input_2_66' type='file' class='medium' aria-describedby=\"gfield_upload_rules_2_66 gfield_description_2_66\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_2_66'>Accepted file types: pdf, jpg, jpeg, png, heic, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_2_66'><\/div> <\/div><\/div><div id=\"field_2_67\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_67'>European Health Insurance Card<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_67'>Valid coverage during your stay.<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_67' id='input_2_67' type='file' class='medium' aria-describedby=\"gfield_upload_rules_2_67 gfield_description_2_67\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_2_67'>Accepted file types: pdf, jpg, jpeg, png, heic, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_2_67'><\/div> <\/div><\/div><div id=\"field_2_68\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_68'>COVID vaccination certificate<\/label><div class='gfield_description' id='gfield_description_2_68'>Optional \u2014 vaccination schedule up to date.<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_68' id='input_2_68' type='file' class='medium' aria-describedby=\"gfield_upload_rules_2_68 gfield_description_2_68\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_2_68'>Accepted file types: pdf, jpg, jpeg, png, heic, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_2_68'><\/div> <\/div><\/div><div id=\"field_2_69\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p style=\"font-size:13px;color:#74BCB6;margin-top:8px;font-style:italic;\">Please bring the last 3 session reports with you when you arrive at the center.<\/p><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_2' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Send request'  \/> <button type='button'  id='gform_save_2_footer_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and forward<\/button>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_2' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_2' id='gform_theme_2' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_2' id='gform_style_settings_2' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            <input type='hidden' class='gform_hidden' 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