{"id":46,"date":"2023-01-18T06:22:42","date_gmt":"2023-01-18T06:22:42","guid":{"rendered":"https:\/\/hardipdave.design\/ataxiaindia\/?page_id=46"},"modified":"2023-01-21T00:33:50","modified_gmt":"2023-01-20T19:03:50","slug":"as-patient","status":"publish","type":"page","link":"https:\/\/www.ataxiaindia.com\/index.php\/as-patient\/","title":{"rendered":"As Patient"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"46\" class=\"elementor elementor-46\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-a2ba627 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"a2ba627\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-5af35c3\" data-id=\"5af35c3\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-8db67e8 elementor-widget elementor-widget-spacer\" data-id=\"8db67e8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-1e306d8 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"1e306d8\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-8083a8a\" data-id=\"8083a8a\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-68713af elementor-widget elementor-widget-shortcode\" data-id=\"68713af\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f9-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"9\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php\/wp-json\/wp\/v2\/pages\/46#wpcf7-f9-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"9\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f9-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_uacf7_hidden_conditional_fields\" value=\"\" \/>\n<\/fieldset>\n\t\t\t\t<style>\n\t\t\t\t\t.uacf7-uacf7style-9 label {\n\t\t\t\t\t\tcolor: #008ad2;font-family: Merriweather;font-style: normal;font-weight: normal;padding-top: 10px;padding-right: 10px;padding-bottom: 10px;padding-left: 10px;margin-bottom: 9px;\t\t\t\t\t}\n\n\t\t\t\t\t.uacf7-uacf7style-9 input[type=\"email\"],\n\t\t\t\t\t.uacf7-uacf7style-9 input[type=\"number\"],\n\t\t\t\t\t.uacf7-uacf7style-9 input[type=\"password\"],\n\t\t\t\t\t.uacf7-uacf7style-9 input[type=\"search\"],\n\t\t\t\t\t.uacf7-uacf7style-9 input[type=\"tel\"],\n\t\t\t\t\t.uacf7-uacf7style-9 input[type=\"text\"],\n\t\t\t\t\t.uacf7-uacf7style-9 input[type=\"url\"],\n\t\t\t\t\t.uacf7-uacf7style-9 input[type=\"date\"],\n\t\t\t\t\t.uacf7-uacf7style-9 input[type=\"radio\"],\n\t\t\t\t\t.uacf7-uacf7style-9 input[type=\"checkbox\"],\n\t\t\t\t\t.uacf7-uacf7style-9 select,\n\t\t\t\t\t.uacf7-uacf7style-9 textarea {\n\t\t\t\t\t\tfont-family: Merriweather;font-style: normal;font-weight: normal;border-width: 1px !important;border-color: #008ad2 !important;border-style: solid!important;border-radius: 10px;padding-top: 10px;padding-right: 10px;padding-bottom: 10px;padding-left: 10px;margin-bottom: 20px;\t\t\t\t\t}\n\n\t\t\t\t\t.uacf7-uacf7style-9 .wpcf7-radio span,\n\t\t\t\t\t.uacf7-uacf7style-9 .wpcf7-checkbox span {\n\t\t\t\t\t\tfont-family: Merriweather;font-style: normal;font-weight: normal;\t\t\t\t\t}\n\n\t\t\t\t\t.uacf7-uacf7style-9 textarea {\n\t\t\t\t\t\t\t\t\t\t\t}\n\n\t\t\t\t\t.wpcf7-form-control-wrap select {\n\t\t\t\t\t\twidth: 100%;\n\t\t\t\t\t}\n\n\t\t\t\t\t.uacf7-uacf7style-9 input[type=\"submit\"] {\n\t\t\t\t\t\tcolor: #008ad2;background-color: #ffffff;font-family: Merriweather;font-style: normal;font-weight: normal;border-width: 1px;border-color: #008ad2;border-style: solid;border-radius: 10px;width: 50%;padding-top: 10px;padding-right: 10px;padding-bottom: 10px;padding-left: 10px;\t\t\t\t\t}\n\n\t\t\t\t\t.uacf7-uacf7style-9 input[type=\"submit\"]:hover {\n\t\t\t\t\t\tcolor: #ffffff;background-color: #008ad2;border-color: #008ad2;\t\t\t\t\t}\n\n\t\t\t\t\t\t\t\t\t<\/style>\n\n\t\t\t\t<div class=\"uacf7-uacf7style uacf7-uacf7style-9\"><div class=\"uacf7-form-wrapper-container uacf7-form-9  uacf7-uacf7style uacf7-uacf7style-9\"><h3 style=\"text-align:center; font-family:merriweather; color:#008ad2; font-weight:bold;\">Patient Personal Details<\/h3>\n<div class=\"uacf7-row\"><div class=\"uacf7-col-3\">  Date of Joining: <span class=\"wpcf7-form-control-wrap\" data-name=\"DateofJoiningUs\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" min=\"2018-01-01\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Date of Joining Us\" value=\"\" type=\"date\" name=\"DateofJoiningUs\" \/><\/span>  <\/div><div class=\"uacf7-col-3\"><span class=\"wpcf7-form-control-wrap\" data-name=\"Prefix\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"Prefix\" value=\"Mr.\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Mr.<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"Prefix\" value=\"Mrs.\" \/><span class=\"wpcf7-list-item-label\">Mrs.<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"Prefix\" value=\"Miss\" \/><span class=\"wpcf7-list-item-label\">Miss<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"Prefix\" value=\"M\/s\" \/><span class=\"wpcf7-list-item-label\">M\/s<\/span><\/label><\/span><\/span><\/span> <\/div><div class=\"uacf7-col-3\"><\/div><div class=\"uacf7-col-3\"> <\/div><\/div>\n\n\n<div class=\"uacf7-row\"><div class=\"uacf7-col-4\">Your Name:* <span class=\"wpcf7-form-control-wrap\" data-name=\"YourName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Your Name\" value=\"\" type=\"text\" name=\"YourName\" \/><\/span><\/div><div class=\"uacf7-col-4\"> Middle Name:* <span class=\"wpcf7-form-control-wrap\" data-name=\"MiddleName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Middle Name\" value=\"\" type=\"text\" name=\"MiddleName\" \/><\/span><\/div><div class=\"uacf7-col-4\"> Last Name:* <span class=\"wpcf7-form-control-wrap\" data-name=\"LastName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last Name\" value=\"\" type=\"text\" name=\"LastName\" \/><\/span> <\/div><\/div>\n\n\n<div class=\"uacf7-row\"><div class=\"uacf7-col-4\">Gender:* <span class=\"wpcf7-form-control-wrap\" data-name=\"Gender\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"Gender\" value=\"Male\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"Gender\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><\/span><\/span><\/div><div class=\"uacf7-col-4\"> Date of Birth:* <span class=\"wpcf7-form-control-wrap\" data-name=\"DateOfBirth\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" min=\"1923-01-01\" max=\"2022-01-20\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Date Of Birth\" value=\"\" type=\"date\" name=\"DateOfBirth\" \/><\/span><\/div><div class=\"uacf7-col-4\"> Marital Status:* <span class=\"wpcf7-form-control-wrap\" data-name=\"MaritalStatus\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"MaritalStatus\" value=\"Married\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Married<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"MaritalStatus\" value=\"Unmarried\" \/><span class=\"wpcf7-list-item-label\">Unmarried<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"MaritalStatus\" value=\"Separated\" \/><span class=\"wpcf7-list-item-label\">Separated<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"MaritalStatus\" value=\"Widow\" \/><span class=\"wpcf7-list-item-label\">Widow<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"MaritalStatus\" value=\"Neglected\" \/><span class=\"wpcf7-list-item-label\">Neglected<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n\n<div class=\"uacf7-row\"><div class=\"uacf7-col-4\">State:* <span class=\"wpcf7-form-control-wrap\" data-name=\"State\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"State\"><option value=\"Select State\">Select State<\/option><option value=\"Andaman and Nikobar (U\/T)\">Andaman and Nikobar (U\/T)<\/option><option value=\"Andhra Pradesh\">Andhra Pradesh<\/option><option value=\"Arunachal Pradesh\">Arunachal Pradesh<\/option><option value=\"Assam\">Assam<\/option><option value=\"Bihar\">Bihar<\/option><option value=\"Chandigarh (U\/T)\">Chandigarh (U\/T)<\/option><option value=\"Chhattisgarh\">Chhattisgarh<\/option><option value=\"Dadra and Nagar Haveli and Daman &amp; Diu (U\/T)\">Dadra and Nagar Haveli and Daman &amp; Diu (U\/T)<\/option><option value=\"Delhi (U\/T)\">Delhi (U\/T)<\/option><option value=\"Goa\">Goa<\/option><option value=\"Gujarat\">Gujarat<\/option><option value=\"Haryana\">Haryana<\/option><option value=\"Himachal Pradesh\">Himachal Pradesh<\/option><option value=\"Jammu and Kashmir (U\/T)\">Jammu and Kashmir (U\/T)<\/option><option value=\"Jharkhand\">Jharkhand<\/option><option value=\"Karnataka\">Karnataka<\/option><option value=\"Kerla\">Kerla<\/option><option value=\"Ladakh (U\/T)\">Ladakh (U\/T)<\/option><option value=\"Lakshadweep (U\/T)\">Lakshadweep (U\/T)<\/option><option value=\"Madhya Pradesh\">Madhya Pradesh<\/option><option value=\"Maharashtra\">Maharashtra<\/option><option value=\"Manipur\">Manipur<\/option><option value=\"Meghalaya\">Meghalaya<\/option><option value=\"Mizoram\">Mizoram<\/option><option value=\"Nagaland\">Nagaland<\/option><option value=\"Odisha\">Odisha<\/option><option value=\"Puducherry (U\/T)\">Puducherry (U\/T)<\/option><option value=\"Punjab\">Punjab<\/option><option value=\"Rajasthan\">Rajasthan<\/option><option value=\"Sikkim\">Sikkim<\/option><option value=\"Tamil Nadu\">Tamil Nadu<\/option><option value=\"Telangana\">Telangana<\/option><option value=\"Tripura\">Tripura<\/option><option value=\"Uttarakhand\">Uttarakhand<\/option><option value=\"Uttar Pradesh\">Uttar Pradesh<\/option><option value=\"West Bengal\">West Bengal<\/option><\/select><\/span>City:* <span class=\"wpcf7-form-control-wrap\" data-name=\"City\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"City\" value=\"\" type=\"text\" name=\"City\" \/><\/span> Pincode:* <span class=\"wpcf7-form-control-wrap\" data-name=\"Pincode\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Pincode\" value=\"\" type=\"number\" name=\"Pincode\" \/><\/span><\/div><div class=\"uacf7-col-4\"> Residential Address:* <span class=\"wpcf7-form-control-wrap\" data-name=\"ResidentialAddress\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Residential Address\" name=\"ResidentialAddress\"><\/textarea><\/span> <\/div><div class=\"uacf7-col-4\"> Mobile:* <span class=\"wpcf7-form-control-wrap\" data-name=\"Mobile\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Mobile\" value=\"\" type=\"tel\" name=\"Mobile\" \/><\/span> WhatsApp:* <span class=\"wpcf7-form-control-wrap\" data-name=\"WhatsApp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"WhatsApp\" value=\"\" type=\"tel\" name=\"WhatsApp\" \/><\/span> Email Address:* <span class=\"wpcf7-form-control-wrap\" data-name=\"EmailAddress\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email Address\" value=\"\" type=\"email\" name=\"EmailAddress\" \/><\/span><\/div><\/div>\n\n\n<div class=\"uacf7-row\"><div class=\"uacf7-col-4\">Education Qualification:* <span class=\"wpcf7-form-control-wrap\" data-name=\"EducationQualification\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Education Qualification\" value=\"\" type=\"text\" name=\"EducationQualification\" \/><\/span> <\/div><div class=\"\">Occupation:* <span class=\"wpcf7-form-control-wrap\" data-name=\"Occupation\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"Occupation\" value=\"Business\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Business<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"Occupation\" value=\"Government Job\" \/><span class=\"wpcf7-list-item-label\">Government Job<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"Occupation\" value=\"Private Job\" \/><span class=\"wpcf7-list-item-label\">Private Job<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"Occupation\" value=\"Retired\" \/><span class=\"wpcf7-list-item-label\">Retired<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"Occupation\" value=\"Unemployed\" \/><span class=\"wpcf7-list-item-label\">Unemployed<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"Occupation\" value=\"Home Maker\" \/><span class=\"wpcf7-list-item-label\">Home Maker<\/span><\/label><\/span><\/span><\/span> <\/div><\/div>\n\n\n<div class=\"uacf7-row\"><div class=\"uacf7-col-4\">Type of Ataxia:* <span class=\"wpcf7-form-control-wrap\" data-name=\"TypeofAtaxia\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"TypeofAtaxia\"><option value=\"Select Type of Ataxia You have\">Select Type of Ataxia You have<\/option><option value=\"Acquired Ataxia\">Acquired Ataxia<\/option><option value=\"Ataxia Telangiectasia\">Ataxia Telangiectasia<\/option><option value=\"Ataxia with Oculomotor Apraxia 1 (AOA1)\">Ataxia with Oculomotor Apraxia 1 (AOA1)<\/option><option value=\"Ataxia with Oculomotor Apraxia 2 (AOA2)\">Ataxia with Oculomotor Apraxia 2 (AOA2)<\/option><option value=\"Congenital Cerebellar Ataxia (CCA)\">Congenital Cerebellar Ataxia (CCA)<\/option><option value=\"Episodic Ataxia 1 (EA1)\">Episodic Ataxia 1 (EA1)<\/option><option value=\"Episodic Ataxia 2 (EA2)\">Episodic Ataxia 2 (EA2)<\/option><option value=\"Friedreich&#039;s Ataxia (FA)\">Friedreich&#039;s Ataxia (FA)<\/option><option value=\"Gluten Ataxia\">Gluten Ataxia<\/option><option value=\"Idiopathic Ataxia\">Idiopathic Ataxia<\/option><option value=\"Spinocerebellar Ataxia (SCA)\">Spinocerebellar Ataxia (SCA)<\/option><option value=\"Spinocerebellar Ataxia 1 (SCA1)\">Spinocerebellar Ataxia 1 (SCA1)<\/option><option value=\"Spinocerebellar Ataxia 2 (SCA2)\">Spinocerebellar Ataxia 2 (SCA2)<\/option><option value=\"Spinocerebellar Ataxia 3 (SCA3)\">Spinocerebellar Ataxia 3 (SCA3)<\/option><option value=\"Spinocerebellar Ataxia 6 (SCA6)\">Spinocerebellar Ataxia 6 (SCA6)<\/option><option value=\"Spinocerebellar Ataxia 7 (SCA7)\">Spinocerebellar Ataxia 7 (SCA7)<\/option><option value=\"Spinocerebellar Ataxia 11 (SCA11)\">Spinocerebellar Ataxia 11 (SCA11)<\/option><option value=\"Spinocerebellar Ataxia 12 (SCA12)\">Spinocerebellar Ataxia 12 (SCA12)<\/option><option value=\"Unknown\">Unknown<\/option><\/select><\/span><\/div><div class=\"uacf7-col-4\"> Year of Diagnosis:* <span class=\"wpcf7-form-control-wrap\" data-name=\"YearofDiagnosis\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Year of Diagnosis\" value=\"\" type=\"text\" name=\"YearofDiagnosis\" \/><\/span><\/div><div class=\"uacf7-col-4\"> Confirmation of type of ataxia through genetic testing:* <span class=\"wpcf7-form-control-wrap\" data-name=\"Confirmationoftypeofataxiathroughgenetictesting\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"Confirmationoftypeofataxiathroughgenetictesting\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"Confirmationoftypeofataxiathroughgenetictesting\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n\n<div class=\"uacf7-row\"><div class=\"uacf7-col-6\"> Name of Testing Laboratory: <span class=\"wpcf7-form-control-wrap\" data-name=\"NameofTestingLaboratory\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name of Testing Laboratory\" value=\"\" type=\"text\" name=\"NameofTestingLaboratory\" \/><\/span> <\/div><div class=\"uacf7-col-6\"> Under treatment of: <span class=\"wpcf7-form-control-wrap\" data-name=\"Undertreatmentof\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Under treatment of\" value=\"\" type=\"text\" name=\"Undertreatmentof\" \/><\/span> <\/div><\/div>\n\n<hr style=\"border-top: 1px solid #008ad2; margin-bottom:10px;\"><h3 style=\"text-align:center; font-family:merriweather; color:#008ad2; font-weight:bold;\">Care Taker Detail<\/h3>\n<hr style=\"border-top: 1px solid #008ad2; margin-bottom:10px;\">\n\n\n<div class=\"uacf7-row\"><div class=\"uacf7-col-4\">First Name:* <span class=\"wpcf7-form-control-wrap\" data-name=\"FirstNameofCaretaker\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First Name\" value=\"\" type=\"text\" name=\"FirstNameofCaretaker\" \/><\/span><\/div><div class=\"uacf7-col-4\">Middle Name:* <span class=\"wpcf7-form-control-wrap\" data-name=\"MiddleNameofCaretaker\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Middle Name\" value=\"\" type=\"text\" name=\"MiddleNameofCaretaker\" \/><\/span> <\/div><div class=\"uacf7-col-4\">Last Name:* <span class=\"wpcf7-form-control-wrap\" data-name=\"LastNameofCaretaker\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last Name\" value=\"\" type=\"text\" name=\"LastNameofCaretaker\" \/><\/span><\/div><\/div>\n\n\n<div class=\"uacf7-row\"><div class=\"uacf7-col-4\">Relation with You:* <span class=\"wpcf7-form-control-wrap\" data-name=\"RelationwithYou\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Relation with You\" value=\"\" type=\"text\" name=\"RelationwithYou\" \/><\/span><\/div><div class=\"uacf7-col-4\">Gender:* <span class=\"wpcf7-form-control-wrap\" data-name=\"GenderOfCaretaker\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"GenderOfCaretaker\" value=\"Male\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"GenderOfCaretaker\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><\/span><\/span> <\/div><div class=\"uacf7-col-4\">Marital Status:* <span class=\"wpcf7-form-control-wrap\" data-name=\"MaritalStatusofCaretaker\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"MaritalStatusofCaretaker\" value=\"Married\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Married<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"MaritalStatusofCaretaker\" value=\"Unmarried\" \/><span class=\"wpcf7-list-item-label\">Unmarried<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"MaritalStatusofCaretaker\" value=\"Separated\" \/><span class=\"wpcf7-list-item-label\">Separated<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"MaritalStatusofCaretaker\" value=\"Widow\" \/><span class=\"wpcf7-list-item-label\">Widow<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"MaritalStatusofCaretaker\" value=\"Neglected\" \/><span class=\"wpcf7-list-item-label\">Neglected<\/span><\/label><\/span><\/span><\/span> <\/div><\/div>\n\n\n<div class=\"uacf7-row\"><div class=\"uacf7-col-4\">Mobile:* <span class=\"wpcf7-form-control-wrap\" data-name=\"MobileofCaretaker\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Mobile\" value=\"\" type=\"tel\" name=\"MobileofCaretaker\" \/><\/span><\/div><div class=\"uacf7-col-4\"> WhatsApp:* <span class=\"wpcf7-form-control-wrap\" data-name=\"WhatsAppofCaretaker\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"WhatsApp\" value=\"\" type=\"tel\" name=\"WhatsAppofCaretaker\" \/><\/span><\/div><div class=\"uacf7-col-4\"> Email Address:* <span class=\"wpcf7-form-control-wrap\" data-name=\"EmailAddressofCaretaker\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email Address\" value=\"\" type=\"email\" name=\"EmailAddressofCaretaker\" \/><\/span><\/div><\/div>\n\n<div class=\"uacf7-row\"><div class=\"uacf7-col-4\">Education: <span class=\"wpcf7-form-control-wrap\" data-name=\"EducationQualificationofCaretaker\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Education Qualification\" value=\"\" type=\"text\" name=\"EducationQualificationofCaretaker\" \/><\/span> <\/div><div class=\"\">Ocupation:* <span class=\"wpcf7-form-control-wrap\" data-name=\"OccupationofCaretaker\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"OccupationofCaretaker\" value=\"Business\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Business<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"OccupationofCaretaker\" value=\"Government Job\" \/><span class=\"wpcf7-list-item-label\">Government Job<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"OccupationofCaretaker\" value=\"Private Job\" \/><span class=\"wpcf7-list-item-label\">Private Job<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"OccupationofCaretaker\" value=\"Retired\" \/><span class=\"wpcf7-list-item-label\">Retired<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"OccupationofCaretaker\" value=\"Unemployed\" \/><span class=\"wpcf7-list-item-label\">Unemployed<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"OccupationofCaretaker\" value=\"Home Maker\" \/><span class=\"wpcf7-list-item-label\">Home Maker<\/span><\/label><\/span><\/span><\/span><\/div><\/div>\n\n\n<div class=\"uacf7-row\"><div class=\"uacf7-col-3\"><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/><\/div><div class=\"uacf7-col-3\"> <\/div><div class=\"uacf7-col-3\"> <\/div><div class=\"uacf7-col-3\"><\/div><\/div><\/div><\/div><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"231\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-49af181 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"49af181\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-547e3fc\" data-id=\"547e3fc\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-283e9d8 elementor-widget elementor-widget-spacer\" data-id=\"283e9d8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-46","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.ataxiaindia.com\/index.php\/wp-json\/wp\/v2\/pages\/46","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.ataxiaindia.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.ataxiaindia.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.ataxiaindia.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.ataxiaindia.com\/index.php\/wp-json\/wp\/v2\/comments?post=46"}],"version-history":[{"count":13,"href":"https:\/\/www.ataxiaindia.com\/index.php\/wp-json\/wp\/v2\/pages\/46\/revisions"}],"predecessor-version":[{"id":909,"href":"https:\/\/www.ataxiaindia.com\/index.php\/wp-json\/wp\/v2\/pages\/46\/revisions\/909"}],"wp:attachment":[{"href":"https:\/\/www.ataxiaindia.com\/index.php\/wp-json\/wp\/v2\/media?parent=46"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}