{"id":1397,"date":"2024-02-19T20:13:24","date_gmt":"2024-02-19T17:13:24","guid":{"rendered":"https:\/\/allurion.vc4.lv\/?page_id=1397"},"modified":"2024-02-19T21:13:34","modified_gmt":"2024-02-19T18:13:34","slug":"application-survey","status":"publish","type":"page","link":"https:\/\/allurion.vc4.lv\/en\/application-survey\/","title":{"rendered":"Application survey"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1397\" class=\"elementor elementor-1397\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-c358c23 e-flex e-con-boxed e-con e-parent\" data-id=\"c358c23\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-98ebb2f e-flex e-con-boxed e-con e-child\" data-id=\"98ebb2f\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a361767 elementor-widget elementor-widget-heading\" data-id=\"a361767\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Fill out our application survey<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-46c2e48 elementor-widget elementor-widget-text-editor\" data-id=\"46c2e48\" data-element_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<p>If you are unsure about any of the questions and the answer is &#8220;I don&#8217;t know&#8221;, we will assess it during the consultation.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-09fa02b elementor-widget elementor-widget-jet-form-builder-form\" data-id=\"09fa02b\" data-element_type=\"widget\" data-widget_type=\"jet-form-builder-form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<link rel='stylesheet' id='wp-block-library-css' href='https:\/\/allurion.vc4.lv\/wp-includes\/css\/dist\/block-library\/style.min.css?ver=6.8.5' media='all' \/>\n<style id=\"jet-form-builder-1396-inline-css\"><\/style><form  class=\"jet-form-builder layout-column submit-type-ajax\" action=\"https:\/\/allurion.vc4.lv\/en\/wp-json\/wp\/v2\/pages\/1397\/?hFDlLc=pZqrhySbpe&amp;method=reload\" method=\"POST\" data-form-id=\"1396\" data-layout=\"column\" enctype=\"multipart\/form-data\" novalidate=\"null\" ssr_validation_method=\"rest\">\r\n<input type=\"hidden\" name=\"_jfb_current_render_states[]\" value=\"DEFAULT.STATE\" data-jfb-sync \/><input type=\"hidden\" class=\"jet-form-builder__field hidden-field\" name=\"_jet_engine_booking_form_id\" data-field-name=\"_jet_engine_booking_form_id\" value=\"1396\">\n<input type=\"hidden\" class=\"jet-form-builder__field hidden-field\" name=\"_jet_engine_refer\" data-field-name=\"_jet_engine_refer\" value=\"https:\/\/allurion.vc4.lv\/en\/wp-json\/wp\/v2\/pages\/1397\/\">\n<input type=\"hidden\" class=\"jet-form-builder__field hidden-field\" name=\"__queried_post_id\" data-field-name=\"__queried_post_id\" value=\"1397\">\n<div class=\"jet-form-builder-page \" data-page=\"1\" data-page-offset=\"75\"><div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Gastric (hiatal) hernia?  <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"1\" value=\"yes\" data-field-name=\"1\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"1\" value=\"no\" data-field-name=\"1\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"1\" value=\"I don&#039;t know\" data-field-name=\"1\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Abnormality of the oesophagus? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"2\" value=\"yes\" data-field-name=\"2\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"2\" value=\"no\" data-field-name=\"2\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"2\" value=\"I don&#039;t know\" data-field-name=\"2\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Acute gastritis (individual assessment in cases of chronic gastritis)  <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"3\" value=\"yes\" data-field-name=\"3\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"3\" value=\"no\" data-field-name=\"3\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"3\" value=\"I don&#039;t know\" data-field-name=\"3\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Ulcers ((oesophageal ulcer; gastric ulcer; duodenal ulcer) no contraindications in case of previously healed ulcers))? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"4\" value=\"yes\" data-field-name=\"4\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"4\" value=\"no\" data-field-name=\"4\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"4\" value=\"I don&#039;t know\" data-field-name=\"4\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Any gastric or oesophageal surgery (anti-reflux surgery; bariatric surgery for gastric reduction; laparoscopic band ligation) <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"5\" value=\"yes\" data-field-name=\"5\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"5\" value=\"no\" data-field-name=\"5\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"5\" value=\"I don&#039;t know\" data-field-name=\"5\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div class=\"jet-form-builder__next-page-wrap\">\n\t\t\t\t\t<button data-jfb-conditional=\"[{&quot;page_state&quot;:&quot;active&quot;}]\" data-jfb-func=\"disable\" class=\"jet-form-builder__next-page\" type=\"button\">Next<\/button>\n\t<\/div>\n<\/div>\n<div class=\"jet-form-builder-page jet-form-builder-page--hidden\" data-page=\"2\" data-page-offset=\"75\">\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Existing gastric balloon currently in the stomach? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"6\" value=\"yes\" data-field-name=\"6\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"6\" value=\"no\" data-field-name=\"6\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"6\" value=\"I don&#039;t know\" data-field-name=\"6\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Severe gastroparesis? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"7\" value=\"yes\" data-field-name=\"7\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"7\" value=\"no\" data-field-name=\"7\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"7\" value=\"I don&#039;t know\" data-field-name=\"7\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Chronic constipation (drug managed? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"8\" value=\"yes\" data-field-name=\"8\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"8\" value=\"no\" data-field-name=\"8\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"8\" value=\"I don&#039;t know\" data-field-name=\"8\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Diverticulosis? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"9\" value=\"yes\" data-field-name=\"9\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"9\" value=\"no\" data-field-name=\"9\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"9\" value=\"I don&#039;t know\" data-field-name=\"9\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Appendicectomy with incision (laparoscopic surgery is not a contraindication? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"10\" value=\"yes\" data-field-name=\"10\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"10\" value=\"no\" data-field-name=\"10\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"10\" value=\"I don&#039;t know\" data-field-name=\"10\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div class=\"jet-form-builder__next-page-wrap\">\n\t\t<button type=\"button\" class=\"jet-form-builder__prev-page\" data-to-page=\"1\">Previous<\/button>\t\t\t<button data-jfb-conditional=\"[{&quot;page_state&quot;:&quot;active&quot;}]\" data-jfb-func=\"disable\" class=\"jet-form-builder__next-page\" type=\"button\">Next<\/button>\n\t<\/div>\n<\/div>\n<div class=\"jet-form-builder-page jet-form-builder-page--hidden\" data-page=\"3\" data-page-offset=\"75\">\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Perforated appendix and surgery? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"11\" value=\"yes\" data-field-name=\"11\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"11\" value=\"no\" data-field-name=\"11\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"11\" value=\"I don&#039;t know\" data-field-name=\"11\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Crohn's disease? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"12\" value=\"yes\" data-field-name=\"12\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"12\" value=\"no\" data-field-name=\"12\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"12\" value=\"I don&#039;t know\" data-field-name=\"12\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Adhesions after bowel surgery? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"13\" value=\"yes\" data-field-name=\"13\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"13\" value=\"no\" data-field-name=\"13\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"13\" value=\"I don&#039;t know\" data-field-name=\"13\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Inability to discontinue regular use of non-steroidal anti-inflammatory drugs (ibuprofen, diflocan, paracetamol) or other drugs irritating the stomach? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"14\" value=\"yes\" data-field-name=\"14\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"14\" value=\"no\" data-field-name=\"14\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"14\" value=\"I don&#039;t know\" data-field-name=\"14\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Use of anticoagulants, inability, or unwillingness to take (PPI drugs)? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"15\" value=\"yes\" data-field-name=\"15\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"15\" value=\"no\" data-field-name=\"15\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"15\" value=\"I don&#039;t know\" data-field-name=\"15\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div class=\"jet-form-builder__next-page-wrap\">\n\t\t<button type=\"button\" class=\"jet-form-builder__prev-page\" data-to-page=\"2\">Previous<\/button>\t\t\t<button data-jfb-conditional=\"[{&quot;page_state&quot;:&quot;active&quot;}]\" data-jfb-func=\"disable\" class=\"jet-form-builder__next-page\" type=\"button\">Next<\/button>\n\t<\/div>\n<\/div>\n<div class=\"jet-form-builder-page jet-form-builder-page--hidden\" data-page=\"4\" data-page-offset=\"75\">\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Heart failure? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"16\" value=\"yes\" data-field-name=\"16\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"16\" value=\"no\" data-field-name=\"16\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"16\" value=\"I don&#039;t know\" data-field-name=\"16\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Liver failure, cirrhosis? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"17\" value=\"yes\" data-field-name=\"17\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"17\" value=\"no\" data-field-name=\"17\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"17\" value=\"I don&#039;t know\" data-field-name=\"17\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Blood clotting disorders? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"18\" value=\"yes\" data-field-name=\"18\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"18\" value=\"no\" data-field-name=\"18\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"18\" value=\"I don&#039;t know\" data-field-name=\"18\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Serious or uncontrolled mental illness? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"19\" value=\"yes\" data-field-name=\"19\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"19\" value=\"no\" data-field-name=\"19\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"19\" value=\"I don&#039;t know\" data-field-name=\"19\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Eating disorders (bulimia, compulsive eating)? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"20\" value=\"yes\" data-field-name=\"20\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"20\" value=\"no\" data-field-name=\"20\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"20\" value=\"I don&#039;t know\" data-field-name=\"20\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div class=\"jet-form-builder__next-page-wrap\">\n\t\t<button type=\"button\" class=\"jet-form-builder__prev-page\" data-to-page=\"3\">Previous<\/button>\t\t\t<button data-jfb-conditional=\"[{&quot;page_state&quot;:&quot;active&quot;}]\" data-jfb-func=\"disable\" class=\"jet-form-builder__next-page\" type=\"button\">Next<\/button>\n\t<\/div>\n<\/div>\n<div class=\"jet-form-builder-page jet-form-builder-page--hidden\" data-page=\"5\" data-page-offset=\"75\">\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Alcoholism, drug addiction? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"21\" value=\"yes\" data-field-name=\"21\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"21\" value=\"no\" data-field-name=\"21\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"21\" value=\"I don&#039;t know\" data-field-name=\"21\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Pancreatitis? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"22\" value=\"yes\" data-field-name=\"22\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"22\" value=\"no\" data-field-name=\"22\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"22\" value=\"I don&#039;t know\" data-field-name=\"22\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Severe respiratory disease (COPD, sleep apnea)? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"23\" value=\"yes\" data-field-name=\"23\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"23\" value=\"no\" data-field-name=\"23\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"23\" value=\"I don&#039;t know\" data-field-name=\"23\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Cancer? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"24\" value=\"yes\" data-field-name=\"24\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"24\" value=\"no\" data-field-name=\"24\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"24\" value=\"I don&#039;t know\" data-field-name=\"24\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Known allergy to polyurethane? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"25\" value=\"yes\" data-field-name=\"25\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"25\" value=\"no\" data-field-name=\"25\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"25\" value=\"I don&#039;t know\" data-field-name=\"25\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Pregnant and breastfeeding women? <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"26\" value=\"yes\" data-field-name=\"26\" data-calculate=\"yes\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Yes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"26\" value=\"no\" data-field-name=\"26\" data-calculate=\"no\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>No<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"26\" value=\"I don&#039;t know\" data-field-name=\"26\" data-calculate=\"dontknow\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I don't know<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div class=\"jet-form-builder__next-page-wrap\">\n\t\t<button type=\"button\" class=\"jet-form-builder__prev-page\" data-to-page=\"4\">Previous<\/button>\t\t\t<button data-jfb-conditional=\"[{&quot;page_state&quot;:&quot;active&quot;}]\" data-jfb-func=\"disable\" class=\"jet-form-builder__next-page\" type=\"button\">Next<\/button>\n\t<\/div>\n<\/div>\n<div class=\"jet-form-builder-page jet-form-builder-page--hidden\" data-page=\"6\" data-page-offset=\"75\">\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-28f84493 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\"><div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Name <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"Your name\" required=\"required\" name=\"vards\" id=\"vards\" type=\"text\" data-field-name=\"vards\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_9pgwPQfX\">\n\t\t\t\t\t<\/div>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\"><div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Surname <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"Your surname\" required=\"required\" name=\"uzvards\" id=\"uzvards\" type=\"text\" data-field-name=\"uzvards\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_htFPH39L\">\n\t\t\t\t\t<\/div>\n<\/div><\/div>\n<\/div>\n\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Email <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"Your email address\" required=\"required\" name=\"e_pasta_adrese\" id=\"e_pasta_adrese\" type=\"email\" data-field-name=\"e_pasta_adrese\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_TVnJhifs\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Phone number <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input placeholder=\"Your phone number\" required=\"required\" name=\"telefona_numurs\" id=\"telefona_numurs\" type=\"tel\" data-field-name=\"telefona_numurs\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_RTzBpYcm\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Preferred method of communication <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"sazinas_veids\" value=\"telefoniski\" data-field-name=\"sazinas_veids\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>Free phone consultation<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"sazinas_veids\" value=\"epasts\" data-field-name=\"sazinas_veids\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I would like to receive an email with more information<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-checkbox-field\" >\n<div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap checkboxes-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-checkbox\">\n<input type=\"checkbox\" name=\"terms1\" value=\"true\" data-field-name=\"terms1\"  class=\"jet-form-builder__field checkboxes-field checkradio-field\" required=\"required\"><span>I agree that by submitting my details I will receive a call or email from a weight loss program manager.<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-checkbox-field\" >\n<div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap checkboxes-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-checkbox\">\n<input type=\"checkbox\" name=\"terms2\" value=\"true\" data-field-name=\"terms2\"  class=\"jet-form-builder__field checkboxes-field checkradio-field\" required=\"required\"><span><p>I agree to the <a href=\"\/privacy-policy\">Privacy Policy<\/a> and allow SIA \"Vesel\u012bbas centrs 4\" to store and process my personal data.<\/p><\/span><\/label><\/div><\/div>\n<\/div>\n\n<input type=\"hidden\" class=\"captcha-token\" name=\"_captcha_token\" value=\"\"\/><div  class=\"jet-form-builder-row field-type-submit-field\" >\n\t<div data-type=\"submit\" class=\"jet-form-builder__action-button-wrapper jet-form-builder__submit-wrap\">\n\t<button class=\"jet-form-builder__action-button jet-form-builder__submit submit-type-ajax\" type=\"submit\">Submit<\/button>\n\t<\/div>\n\t\n<\/div><\/div>\t<div class=\"jet-form-builder-messages-wrap\" data-form-id=\"1396\"><\/div>\n<\/form>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Fill out our application survey If you are unsure about any of the questions and the answer is &#8220;I don&#8217;t know&#8221;, we will assess it during the consultation. Gastric (hiatal) hernia? * Yes No I don&#8217;t know Abnormality of the oesophagus? * Yes No I don&#8217;t know Acute gastritis (individual assessment in cases of chronic [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1397","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/allurion.vc4.lv\/en\/wp-json\/wp\/v2\/pages\/1397","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/allurion.vc4.lv\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/allurion.vc4.lv\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/allurion.vc4.lv\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/allurion.vc4.lv\/en\/wp-json\/wp\/v2\/comments?post=1397"}],"version-history":[{"count":13,"href":"https:\/\/allurion.vc4.lv\/en\/wp-json\/wp\/v2\/pages\/1397\/revisions"}],"predecessor-version":[{"id":1415,"href":"https:\/\/allurion.vc4.lv\/en\/wp-json\/wp\/v2\/pages\/1397\/revisions\/1415"}],"wp:attachment":[{"href":"https:\/\/allurion.vc4.lv\/en\/wp-json\/wp\/v2\/media?parent=1397"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}