{
    "id": 123454,
    "date": "2024-03-19T21:01:43",
    "date_gmt": "2024-03-19T10:01:43",
    "guid": {
        "rendered": "https:\/\/aestheticmet.com\/?page_id=123454"
    },
    "modified": "2024-11-05T19:45:32",
    "modified_gmt": "2024-11-05T08:45:32",
    "slug": "ae-form-for-hcps",
    "status": "publish",
    "type": "page",
    "link": "https:\/\/global.aestheticmet.com\/jp\/en_au\/ae-form-for-hcps\/",
    "title": {
        "rendered": "AE Form for HCPs"
    },
    "content": {
        "rendered": "<div data-elementor-type=\"wp-page\" data-elementor-id=\"123454\" class=\"elementor elementor-123454\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-625ddc6 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"625ddc6\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-939151a\" data-id=\"939151a\" 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-80fb4f7 elementor-widget elementor-widget-heading\" data-id=\"80fb4f7\" data-element_type=\"widget\" data-e-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\">Adverse Event Form for HCP's<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-4840242 elementor-widget elementor-widget-formidable\" data-id=\"4840242\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"formidable.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_17_container\" data-token=\"980e54d8a03103942a04f011b014968d\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_js_validate  frm_ajax_submit  frm_pro_form\" id=\"form_adverse-event-hcp22\" data-frm-error-config=\"{&quot;includeAlertRole&quot;:false,&quot;focusFirstError&quot;:false,&quot;focusErrorSummary&quot;:true}\" data-token=\"980e54d8a03103942a04f011b014968d\" action=\"\">\n<div class=\"frm_form_fields\">\n<fieldset>\n<legend class=\"frm_screen_reader\">Adverse Event (HCP) JAPAN ONLY<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"17\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_17\" id=\"frm_hide_fields_17\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"adverse-event-hcp22\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_17\" name=\"frm_submit_entry_17\" value=\"1ee7c250e4\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/jp\/en_au\/wp-json\/wp\/v2\/pages\/123454\" \/><div id=\"frm_field_269_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_first\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Healthcare professional details<\/h3>\r\n\r\n\r\n<input type=\"hidden\" name=\"item_meta[270]\" id=\"field_dei8h2\" value=\"\" data-frmval=\"\"\/>\n<div id=\"frm_field_271_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first\">\r\n    <div id=\"field_ovnxw_label\" class=\"frm_primary_label\">Name\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_ovnxw_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tName\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_271\" data-reqmsg=\"Name cannot be blank.\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_271-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_ovnxw_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_ovnxw_first\" value=\"\" name=\"item_meta[271][first]\" autocomplete=\"given-name\" data-sectionid=\"269\" data-reqmsg=\"First cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_271_first_desc\">First<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_271-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_ovnxw_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_ovnxw_last\" value=\"\" name=\"item_meta[271][last]\" autocomplete=\"family-name\" data-sectionid=\"269\" data-reqmsg=\"Last cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_271_last_desc\">Last<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_272_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_7y9h6\" id=\"field_7y9h6_label\" class=\"frm_primary_label\">Mobile Number\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_7y9h6\" name=\"item_meta[272]\" value=\"\"  data-sectionid=\"269\" data-reqmsg=\"Mobile Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Mobile Number is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_273_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div id=\"field_pv2l9_label\" class=\"frm_primary_label\">Are you an AMET member?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_273-269-0\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[273]\" id=\"field_pv2l9-0\" value=\"Yes\"\n\t\t data-sectionid=\"269\" data-reqmsg=\"Are you an AMET member? cannot be blank.\" data-invmsg=\"Are you an AMET member? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_273-269-1\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[273]\" id=\"field_pv2l9-1\" value=\"No\"\n\t\t data-sectionid=\"269\" data-reqmsg=\"Are you an AMET member? cannot be blank.\" data-invmsg=\"Are you an AMET member? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_274_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_lzgsc\" id=\"field_lzgsc_label\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_lzgsc\" name=\"item_meta[274]\" value=\"\"  data-sectionid=\"269\"autocomplete=\"email\" data-reqmsg=\"Email cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\" aria-describedby=\"frm_desc_field_lzgsc\"  \/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_lzgsc\">If you are an existing AMET Member please enter your registered AMET email address. A copy of this completed form will be sent to the email address you provide.<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_275_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio frm_other_container\">\r\n    <div id=\"field_aqsxv_label\" class=\"frm_primary_label\">What is your professional title?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_275-269-0\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[275]\" id=\"field_aqsxv-0\" value=\"Medical practitioner \u2013 specialist registration\"\n\t\t data-sectionid=\"269\" data-reqmsg=\"What is your professional title? cannot be blank.\" data-invmsg=\"What is your professional title? is invalid\"   \/> Medical practitioner \u2013 specialist registration<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_275-269-1\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[275]\" id=\"field_aqsxv-1\" value=\"Medical practitioner \u2013 general registration\"\n\t\t data-sectionid=\"269\" data-reqmsg=\"What is your professional title? cannot be blank.\" data-invmsg=\"What is your professional title? is invalid\"   \/> Medical practitioner \u2013 general registration<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_275-269-2\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[275]\" id=\"field_aqsxv-2\" value=\"Nurse Practitioner\"\n\t\t data-sectionid=\"269\" data-reqmsg=\"What is your professional title? cannot be blank.\" data-invmsg=\"What is your professional title? is invalid\"   \/> Nurse Practitioner<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_275-269-3\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[275]\" id=\"field_aqsxv-3\" value=\"Registered Nurse\"\n\t\t data-sectionid=\"269\" data-reqmsg=\"What is your professional title? cannot be blank.\" data-invmsg=\"What is your professional title? is invalid\"   \/> Registered Nurse<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_275-269-4\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[275]\" id=\"field_aqsxv-4\" value=\"Enrolled Nurse\"\n\t\t data-sectionid=\"269\" data-reqmsg=\"What is your professional title? cannot be blank.\" data-invmsg=\"What is your professional title? is invalid\"   \/> Enrolled Nurse<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_275-269-other_5\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[275]\" id=\"field_aqsxv-other_5\" value=\"Other\"\n\t\t data-sectionid=\"269\" data-reqmsg=\"What is your professional title? cannot be blank.\" data-invmsg=\"What is your professional title? is invalid\"   \/> Other<\/label><label for=\"field_aqsxv-other_5-otext\" class=\"frm_screen_reader frm_hidden\">Other<\/label><input type=\"text\" id=\"field_aqsxv-other_5-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][275]\" value=\"\" \/><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_276_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div id=\"field_uu8i4_label\" class=\"frm_primary_label\">Practitioner years of Aesthetic medicine experience\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_276-269-0\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[276]\" id=\"field_uu8i4-0\" value=\"Less than 1 year\"\n\t\t data-sectionid=\"269\" data-reqmsg=\"Practitioner years of Aesthetic medicine experience cannot be blank.\" data-invmsg=\"Practitioner years of Aesthetic medicine experience is invalid\"   \/> Less than 1 year<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_276-269-1\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[276]\" id=\"field_uu8i4-1\" value=\"1-2\"\n\t\t data-sectionid=\"269\" data-reqmsg=\"Practitioner years of Aesthetic medicine experience cannot be blank.\" data-invmsg=\"Practitioner years of Aesthetic medicine experience is invalid\"   \/> 1-2<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_276-269-2\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[276]\" id=\"field_uu8i4-2\" value=\"2-5\"\n\t\t data-sectionid=\"269\" data-reqmsg=\"Practitioner years of Aesthetic medicine experience cannot be blank.\" data-invmsg=\"Practitioner years of Aesthetic medicine experience is invalid\"   \/> 2-5<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_276-269-3\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[276]\" id=\"field_uu8i4-3\" value=\"5-10\"\n\t\t data-sectionid=\"269\" data-reqmsg=\"Practitioner years of Aesthetic medicine experience cannot be blank.\" data-invmsg=\"Practitioner years of Aesthetic medicine experience is invalid\"   \/> 5-10<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_276-269-4\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[276]\" id=\"field_uu8i4-4\" value=\"10 years plus\"\n\t\t data-sectionid=\"269\" data-reqmsg=\"Practitioner years of Aesthetic medicine experience cannot be blank.\" data-invmsg=\"Practitioner years of Aesthetic medicine experience is invalid\"   \/> 10 years plus<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_277_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_rd663\" id=\"field_rd663_label\" class=\"frm_primary_label\">Country\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[277]\" id=\"field_rd663\"  data-sectionid=\"269\" data-reqmsg=\"Country cannot be blank.\" aria-required=\"true\" data-invmsg=\"Country is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"Australia\">Australia<\/option><option  value=\"New Zealand\">New Zealand<\/option><option  value=\"Afghanistan\">Afghanistan<\/option><option  value=\"Aland Islands\">Aland Islands<\/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=\"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\">Brunei<\/option><option  value=\"Bulgaria\">Bulgaria<\/option><option  value=\"Burkina Faso\">Burkina Faso<\/option><option  value=\"Burundi\">Burundi<\/option><option  value=\"C\u00f4te d&#039;Ivoire\">C\u00f4te d&#039;Ivoire<\/option><option  value=\"Cambodia\">Cambodia<\/option><option  value=\"Cameroon\">Cameroon<\/option><option  value=\"Canada\">Canada<\/option><option  value=\"Cape Verde\">Cape Verde<\/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 (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option  value=\"Colombia\">Colombia<\/option><option  value=\"Comoros\">Comoros<\/option><option  value=\"Congo\">Congo<\/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=\"Curacao\">Curacao<\/option><option  value=\"Cyprus\">Cyprus<\/option><option  value=\"Czech Republic\">Czech Republic<\/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=\"East Timor\">East Timor<\/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=\"Ethiopia\">Ethiopia<\/option><option  value=\"Falkland Islands (Malvinas)\">Falkland Islands (Malvinas)<\/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=\"Kosovo\">Kosovo<\/option><option  value=\"Kuwait\">Kuwait<\/option><option  value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option  value=\"Laos\">Laos<\/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=\"Macedonia\">Macedonia<\/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=\"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 Korea\">North Korea<\/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\">Palestine<\/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=\"Reunion\">Reunion<\/option><option  value=\"Romania\">Romania<\/option><option  value=\"Russia\">Russia<\/option><option  value=\"Rwanda\">Rwanda<\/option><option  value=\"Saint Barthelemy\">Saint Barthelemy<\/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 (French part)\">Saint Martin (French part)<\/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 (Dutch part)\">Sint Maarten (Dutch part)<\/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 Korea\">South Korea<\/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=\"Swaziland\">Swaziland<\/option><option  value=\"Sweden\">Sweden<\/option><option  value=\"Switzerland\">Switzerland<\/option><option  value=\"Syria\">Syria<\/option><option  value=\"Taiwan\">Taiwan<\/option><option  value=\"Tajikistan\">Tajikistan<\/option><option  value=\"Tanzania\">Tanzania<\/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=\"Turkey\">Turkey<\/option><option  value=\"Turkmenistan\">Turkmenistan<\/option><option  value=\"Turks and Caicos Islands\">Turks and Caicos Islands<\/option><option  value=\"Tuvalu\">Tuvalu<\/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=\"United States Minor Outlying Islands\">United States Minor Outlying Islands<\/option><option  value=\"Uruguay\">Uruguay<\/option><option  value=\"Uzbekistan\">Uzbekistan<\/option><option  value=\"Vanuatu\">Vanuatu<\/option><option  value=\"Vatican City\">Vatican City<\/option><option  value=\"Venezuela\">Venezuela<\/option><option  value=\"Vietnam\">Vietnam<\/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>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_278_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_qdrxm\" id=\"field_qdrxm_label\" class=\"frm_primary_label\">State\/Region\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_qdrxm\" name=\"item_meta[278]\" value=\"\"  data-sectionid=\"269\" data-reqmsg=\"State\/Region cannot be blank.\" aria-required=\"true\" data-invmsg=\"State\/Region is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_279_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_xax8v\" id=\"field_xax8v_label\" class=\"frm_primary_label\">City\/Town\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xax8v\" name=\"item_meta[279]\" value=\"\"  data-sectionid=\"269\" data-reqmsg=\"City\/Town cannot be blank.\" aria-required=\"true\" data-invmsg=\"City\/Town is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_281_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_first\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Adverse Event Details<\/h3>\r\n\r\n\r\n<div id=\"frm_field_283_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n    <label for=\"field_h7t5m\" id=\"field_h7t5m_label\" class=\"frm_primary_label\">Reported Adverse Event Date\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_h7t5m\" name=\"item_meta[283]\" value=\"\"  data-sectionid=\"281\" maxlength=\"10\" data-reqmsg=\"Reported Adverse Event Date cannot be blank.\" aria-required=\"true\" data-invmsg=\"Reported Adverse Event Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_284_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n    <label for=\"field_4vma82\" id=\"field_4vma82_label\" class=\"frm_primary_label\">Treatment Date\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_4vma82\" name=\"item_meta[284]\" value=\"\"  data-sectionid=\"281\" maxlength=\"10\" data-reqmsg=\"Treatment Date cannot be blank.\" aria-required=\"true\" data-invmsg=\"Treatment Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_285_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <div id=\"field_zq5c7_label\" class=\"frm_primary_label\">Treatment Time\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_time_wrap\"><span dir=\"ltr\">\r\n<select aria-label=\"Treatment Time ... hour\" name=\"item_meta[285][H]\" id=\"field_zq5c7_H\"  data-sectionid=\"281\" data-frmval=\"{&quot;H&quot;:&quot;&quot;,&quot;m&quot;:&quot;&quot;,&quot;A&quot;:&quot;&quot;,&quot;s&quot;:&quot;&quot;,&quot;ms&quot;:&quot;&quot;}\" data-invmsg=\"Treatment Time is invalid\" class=\"auto_width frm_time_select\" aria-invalid=\"false\"  ><option value=\"\"  selected='selected'><\/option><option value=\"12\" >12<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><\/select>\r\n<span class=\"frm_time_sep\" aria-hidden=\"true\">:<\/span>\r\n<select aria-label=\"Treatment Time ... minute\" name=\"item_meta[285][m]\" id=\"field_zq5c7_m\"  data-sectionid=\"281\" data-frmval=\"{&quot;H&quot;:&quot;&quot;,&quot;m&quot;:&quot;&quot;,&quot;A&quot;:&quot;&quot;,&quot;s&quot;:&quot;&quot;,&quot;ms&quot;:&quot;&quot;}\" data-invmsg=\"Treatment Time is invalid\" class=\"auto_width frm_time_select auto_width frm_time_select\" aria-invalid=\"false\"  ><option value=\"\"  selected='selected'><\/option><option value=\"00\" >00<\/option><option value=\"30\" >30<\/option><\/select>\r\n<\/span>\r\n<select aria-label=\"Treatment Time\" name=\"item_meta[285][A]\" id=\"field_zq5c7_A\"  data-sectionid=\"281\" data-frmval=\"{&quot;H&quot;:&quot;&quot;,&quot;m&quot;:&quot;&quot;,&quot;A&quot;:&quot;&quot;,&quot;s&quot;:&quot;&quot;,&quot;ms&quot;:&quot;&quot;}\" data-invmsg=\"Treatment Time is invalid\" class=\"auto_width frm_time_select auto_width frm_time_select auto_width frm_time_select\" aria-invalid=\"false\"  ><option value=\"AM\" >AM<\/option><option value=\"PM\" >PM<\/option><\/select>\r\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_286_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio frm_other_container\">\r\n    <div id=\"field_gd7tx_label\" class=\"frm_primary_label\">Treatment type (please tick all that apply)\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_286-281-0\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[286][]\" id=\"field_gd7tx-0\" value=\"Hyaluronic acid injectable filler and\/or gel.\"  data-sectionid=\"281\" data-reqmsg=\"Treatment type (please tick all that apply) cannot be blank.\" data-invmsg=\"Treatment type (please tick all that apply) is invalid\"   aria-required=\"true\"  \/> Hyaluronic acid injectable filler and\/or gel.<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_286-281-1\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[286][]\" id=\"field_gd7tx-1\" value=\"Permanent filler injections.\"  data-sectionid=\"281\" data-reqmsg=\"Treatment type (please tick all that apply) cannot be blank.\" data-invmsg=\"Treatment type (please tick all that apply) is invalid\"   \/> Permanent filler injections.<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_286-281-2\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[286][]\" id=\"field_gd7tx-2\" value=\"Botulinum toxin\"  data-sectionid=\"281\" data-reqmsg=\"Treatment type (please tick all that apply) cannot be blank.\" data-invmsg=\"Treatment type (please tick all that apply) is invalid\"   \/> Botulinum toxin<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_286-281-3\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[286][]\" id=\"field_gd7tx-3\" value=\"Polylactic acid (PLLA or PDLLA)\"  data-sectionid=\"281\" data-reqmsg=\"Treatment type (please tick all that apply) cannot be blank.\" data-invmsg=\"Treatment type (please tick all that apply) is invalid\"   \/> Polylactic acid (PLLA or PDLLA)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_286-281-4\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[286][]\" id=\"field_gd7tx-4\" value=\"Polycaprolactone\"  data-sectionid=\"281\" data-reqmsg=\"Treatment type (please tick all that apply) cannot be blank.\" data-invmsg=\"Treatment type (please tick all that apply) is invalid\"   \/> Polycaprolactone<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_286-281-5\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[286][]\" id=\"field_gd7tx-5\" value=\"Calcium Hydroxylapatite\"  data-sectionid=\"281\" data-reqmsg=\"Treatment type (please tick all that apply) cannot be blank.\" data-invmsg=\"Treatment type (please tick all that apply) is invalid\"   \/> Calcium Hydroxylapatite<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_286-281-6\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[286][]\" id=\"field_gd7tx-6\" value=\"Polynucleotide\"  data-sectionid=\"281\" data-reqmsg=\"Treatment type (please tick all that apply) cannot be blank.\" data-invmsg=\"Treatment type (please tick all that apply) is invalid\"   \/> Polynucleotide<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_286-281-7\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[286][]\" id=\"field_gd7tx-7\" value=\"Platelet rich plasma (PRP)\"  data-sectionid=\"281\" data-reqmsg=\"Treatment type (please tick all that apply) cannot be blank.\" data-invmsg=\"Treatment type (please tick all that apply) is invalid\"   \/> Platelet rich plasma (PRP)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_286-281-8\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[286][]\" id=\"field_gd7tx-8\" value=\"Monofilament threads (collagen stimulating only)\"  data-sectionid=\"281\" data-reqmsg=\"Treatment type (please tick all that apply) cannot be blank.\" data-invmsg=\"Treatment type (please tick all that apply) is invalid\"   \/> Monofilament threads (collagen stimulating only)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_286-281-9\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[286][]\" id=\"field_gd7tx-9\" value=\"Thread lift (cogged \/ barbed threads)\"  data-sectionid=\"281\" data-reqmsg=\"Treatment type (please tick all that apply) cannot be blank.\" data-invmsg=\"Treatment type (please tick all that apply) is invalid\"   \/> Thread lift (cogged \/ barbed threads)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_286-281-10\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[286][]\" id=\"field_gd7tx-10\" value=\"Hyaluronidase\"  data-sectionid=\"281\" data-reqmsg=\"Treatment type (please tick all that apply) cannot be blank.\" data-invmsg=\"Treatment type (please tick all that apply) is invalid\"   \/> Hyaluronidase<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_286-281-11\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[286][]\" id=\"field_gd7tx-11\" value=\"Energy based device\"  data-sectionid=\"281\" data-reqmsg=\"Treatment type (please tick all that apply) cannot be blank.\" data-invmsg=\"Treatment type (please tick all that apply) is invalid\"   \/> Energy based device<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_286-281-13\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[286][]\" id=\"field_gd7tx-13\" value=\"Injectable lipolysis (Deoxycholic acid)\"  data-sectionid=\"281\" data-reqmsg=\"Treatment type (please tick all that apply) cannot be blank.\" data-invmsg=\"Treatment type (please tick all that apply) is invalid\"   \/> Injectable lipolysis (Deoxycholic acid)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_286-281-other_12\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[286][other_12]\" id=\"field_gd7tx-other_12\" value=\"Other or unknown\"  data-sectionid=\"281\" data-reqmsg=\"Treatment type (please tick all that apply) cannot be blank.\" data-invmsg=\"Treatment type (please tick all that apply) is invalid\"   \/> Other or unknown<\/label><label for=\"field_gd7tx-other_12-otext\" class=\"frm_screen_reader frm_hidden\">Other or unknown<\/label><input type=\"text\" id=\"field_gd7tx-other_12-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][286][other_12]\" value=\"\" \/><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_287_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio frm_other_container\">\r\n    <div id=\"field_9zggo_label\" class=\"frm_primary_label\">What is the suspected or confirmed diagnosis? (Please tick all that may apply)\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_287-281-0\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[287][]\" id=\"field_9zggo-0\" value=\"Anaphylaxis \/ life threatening allergic reaction\"  data-sectionid=\"281\" data-reqmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) cannot be blank.\" data-invmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) is invalid\"   aria-required=\"true\"  \/> Anaphylaxis \/ life threatening allergic reaction<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_287-281-1\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[287][]\" id=\"field_9zggo-1\" value=\"Angioedema \/ severe swelling (not anaphylaxis)\"  data-sectionid=\"281\" data-reqmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) cannot be blank.\" data-invmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) is invalid\"   \/> Angioedema \/ severe swelling (not anaphylaxis)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_287-281-2\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[287][]\" id=\"field_9zggo-2\" value=\"Allergic reaction \u2013 non-life threatening\"  data-sectionid=\"281\" data-reqmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) cannot be blank.\" data-invmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) is invalid\"   \/> Allergic reaction \u2013 non-life threatening<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_287-281-3\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[287][]\" id=\"field_9zggo-3\" value=\"Vascular occlusion\"  data-sectionid=\"281\" data-reqmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) cannot be blank.\" data-invmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) is invalid\"   \/> Vascular occlusion<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_287-281-4\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[287][]\" id=\"field_9zggo-4\" value=\"Inflammatory reaction\"  data-sectionid=\"281\" data-reqmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) cannot be blank.\" data-invmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) is invalid\"   \/> Inflammatory reaction<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_287-281-5\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[287][]\" id=\"field_9zggo-5\" value=\"Non-fluctuant (fixed \/ firm) nodule\"  data-sectionid=\"281\" data-reqmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) cannot be blank.\" data-invmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) is invalid\"   \/> Non-fluctuant (fixed \/ firm) nodule<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_287-281-6\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[287][]\" id=\"field_9zggo-6\" value=\"Fluctuant (malleable) nodule\"  data-sectionid=\"281\" data-reqmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) cannot be blank.\" data-invmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) is invalid\"   \/> Fluctuant (malleable) nodule<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_287-281-7\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[287][]\" id=\"field_9zggo-7\" value=\"Abscess\"  data-sectionid=\"281\" data-reqmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) cannot be blank.\" data-invmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) is invalid\"   \/> Abscess<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_287-281-8\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[287][]\" id=\"field_9zggo-8\" value=\"Non-inflammatory nodule\"  data-sectionid=\"281\" data-reqmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) cannot be blank.\" data-invmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) is invalid\"   \/> Non-inflammatory nodule<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_287-281-9\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[287][]\" id=\"field_9zggo-9\" value=\"Haematoma \/ bruise\"  data-sectionid=\"281\" data-reqmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) cannot be blank.\" data-invmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) is invalid\"   \/> Haematoma \/ bruise<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_287-281-10\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[287][]\" id=\"field_9zggo-10\" value=\"Cellulitis\"  data-sectionid=\"281\" data-reqmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) cannot be blank.\" data-invmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) is invalid\"   \/> Cellulitis<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_287-281-11\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[287][]\" id=\"field_9zggo-11\" value=\"Herpes simplex (Cold sores)\"  data-sectionid=\"281\" data-reqmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) cannot be blank.\" data-invmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) is invalid\"   \/> Herpes simplex (Cold sores)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_287-281-12\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[287][]\" id=\"field_9zggo-12\" value=\"Skin infection (other)\"  data-sectionid=\"281\" data-reqmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) cannot be blank.\" data-invmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) is invalid\"   \/> Skin infection (other)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_287-281-13\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[287][]\" id=\"field_9zggo-13\" value=\"Neuropraxia (nerve injury)\"  data-sectionid=\"281\" data-reqmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) cannot be blank.\" data-invmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) is invalid\"   \/> Neuropraxia (nerve injury)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_287-281-14\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[287][]\" id=\"field_9zggo-14\" value=\"Paresis or palsy\"  data-sectionid=\"281\" data-reqmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) cannot be blank.\" data-invmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) is invalid\"   \/> Paresis or palsy<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_287-281-15\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[287][]\" id=\"field_9zggo-15\" value=\"Blepharoptosis\"  data-sectionid=\"281\" data-reqmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) cannot be blank.\" data-invmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) is invalid\"   \/> Blepharoptosis<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_287-281-16\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[287][]\" id=\"field_9zggo-16\" value=\"Muscle weakness\"  data-sectionid=\"281\" data-reqmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) cannot be blank.\" data-invmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) is invalid\"   \/> Muscle weakness<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_287-281-other_17\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[287][other_17]\" id=\"field_9zggo-other_17\" value=\"Other or Unknown\"  data-sectionid=\"281\" data-reqmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) cannot be blank.\" data-invmsg=\"What is the suspected or confirmed diagnosis? (Please tick all that may apply) is invalid\"   \/> Other or Unknown<\/label><label for=\"field_9zggo-other_17-otext\" class=\"frm_screen_reader frm_hidden\">Other or Unknown<\/label><input type=\"text\" id=\"field_9zggo-other_17-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][287][other_17]\" value=\"\" \/><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_288_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio frm_other_container\">\r\n    <div id=\"field_vq0dc_label\" class=\"frm_primary_label\">Please tick all clinical symptoms the patient is experiencing?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-0\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-0\" value=\"Loss of consciousness\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   aria-required=\"true\"  \/> Loss of consciousness<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-24\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-24\" value=\"Loss of vision - partial\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Loss of vision - partial<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-1\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-1\" value=\"Loss of vision - complete\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Loss of vision - complete<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-25\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-25\" value=\"Blurred or double vision\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Blurred or double vision<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-2\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-2\" value=\"Seizure\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Seizure<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-3\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-3\" value=\"Headache\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Headache<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-4\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-4\" value=\"Febrile \/ fever\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Febrile \/ fever<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-5\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-5\" value=\"Fatigue or general malaise\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Fatigue or general malaise<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-6\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-6\" value=\"Skin discolouration\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Skin discolouration<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-7\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-7\" value=\"Livedo reticularis\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Livedo reticularis<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-8\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-8\" value=\"Blisters or ulcerated tissue\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Blisters or ulcerated tissue<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-9\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-9\" value=\"Necrosis\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Necrosis<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-10\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-10\" value=\"Pain at rest\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Pain at rest<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-11\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-11\" value=\"Pain on palpation or movement\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Pain on palpation or movement<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-12\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-12\" value=\"Erythema (redness)\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Erythema (redness)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-13\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-13\" value=\"Warmth or heat\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Warmth or heat<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-14\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-14\" value=\"Swelling \u2013 moderate to severe\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Swelling \u2013 moderate to severe<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-15\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-15\" value=\"Swelling \u2013 mild\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Swelling \u2013 mild<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-16\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-16\" value=\"Swelling \u2013 intermittent \/ transient\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Swelling \u2013 intermittent \/ transient<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-17\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-17\" value=\"Rash\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Rash<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-18\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-18\" value=\"Urticaria (Hives)\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Urticaria (Hives)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-19\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-19\" value=\"Altered \/ impaired sensation (e.g. numbness, tingling etc).\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Altered \/ impaired sensation (e.g. numbness, tingling etc).<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-20\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-20\" value=\"Visible nodule(s) or lumps\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Visible nodule(s) or lumps<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-21\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-21\" value=\"Palpable nodule(s) only (not visible)\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Palpable nodule(s) only (not visible)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-22\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-22\" value=\"Loss of movement \/ muscle function\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Loss of movement \/ muscle function<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-26\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-26\" value=\"Haematoma\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Haematoma<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-27\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][]\" id=\"field_vq0dc-27\" value=\"Sluggish capillary refill\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Sluggish capillary refill<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_288-281-other_23\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[288][other_23]\" id=\"field_vq0dc-other_23\" value=\"Other\"  data-sectionid=\"281\" data-reqmsg=\"Please tick all clinical symptoms the patient is experiencing? cannot be blank.\" data-invmsg=\"Please tick all clinical symptoms the patient is experiencing? is invalid\"   \/> Other<\/label><label for=\"field_vq0dc-other_23-otext\" class=\"frm_screen_reader frm_hidden\">Other<\/label><input type=\"text\" id=\"field_vq0dc-other_23-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][288][other_23]\" value=\"\" \/><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_289_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div id=\"field_ttorj_label\" class=\"frm_primary_label\">Clinical symptom presentation (Please tick all that apply)\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_289-281-0\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[289]\" id=\"field_ttorj-0\" value=\"Bilateral\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"Clinical symptom presentation (Please tick all that apply) cannot be blank.\" data-invmsg=\"Clinical symptom presentation (Please tick all that apply) is invalid\"   \/> Bilateral<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_289-281-1\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[289]\" id=\"field_ttorj-1\" value=\"Unilateral - Right side\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"Clinical symptom presentation (Please tick all that apply) cannot be blank.\" data-invmsg=\"Clinical symptom presentation (Please tick all that apply) is invalid\"   \/> Unilateral - Right side<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_289-281-2\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[289]\" id=\"field_ttorj-2\" value=\"Unilateral - Left side\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"Clinical symptom presentation (Please tick all that apply) cannot be blank.\" data-invmsg=\"Clinical symptom presentation (Please tick all that apply) is invalid\"   \/> Unilateral - Left side<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_289-281-3\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[289]\" id=\"field_ttorj-3\" value=\"Diffuse or unconfined\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"Clinical symptom presentation (Please tick all that apply) cannot be blank.\" data-invmsg=\"Clinical symptom presentation (Please tick all that apply) is invalid\"   \/> Diffuse or unconfined<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_289-281-4\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[289]\" id=\"field_ttorj-4\" value=\"Intermittent \/ transient symptoms\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"Clinical symptom presentation (Please tick all that apply) cannot be blank.\" data-invmsg=\"Clinical symptom presentation (Please tick all that apply) is invalid\"   \/> Intermittent \/ transient symptoms<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_289-281-5\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[289]\" id=\"field_ttorj-5\" value=\"Constant \/ frequent symptoms\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"Clinical symptom presentation (Please tick all that apply) cannot be blank.\" data-invmsg=\"Clinical symptom presentation (Please tick all that apply) is invalid\"   \/> Constant \/ frequent symptoms<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_289-281-6\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[289]\" id=\"field_ttorj-6\" value=\"Inconsistent  \/ changing symptoms\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"Clinical symptom presentation (Please tick all that apply) cannot be blank.\" data-invmsg=\"Clinical symptom presentation (Please tick all that apply) is invalid\"   \/> Inconsistent  \/ changing symptoms<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_289-281-other_5\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[289]\" id=\"field_ttorj-other_5\" value=\"Other\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"Clinical symptom presentation (Please tick all that apply) cannot be blank.\" data-invmsg=\"Clinical symptom presentation (Please tick all that apply) is invalid\"   \/> Other<\/label><label for=\"field_ttorj-other_5-otext\" class=\"frm_screen_reader frm_hidden\">Other<\/label><input type=\"text\" id=\"field_ttorj-other_5-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][289]\" value=\"\" \/><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_290_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div id=\"field_f354t2_label\" class=\"frm_primary_label\">When did the clinical symptoms initially present?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_290-281-0\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[290]\" id=\"field_f354t2-0\" value=\"Immediately (at the time of or immediately after treatment)\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"When did the clinical symptoms initially present? cannot be blank.\" data-invmsg=\"When did the clinical symptoms initially present? is invalid\"   \/> Immediately (at the time of or immediately after treatment)<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_290-281-1\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[290]\" id=\"field_f354t2-1\" value=\"Within 24 hours\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"When did the clinical symptoms initially present? cannot be blank.\" data-invmsg=\"When did the clinical symptoms initially present? is invalid\"   \/> Within 24 hours<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_290-281-2\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[290]\" id=\"field_f354t2-2\" value=\"Within 2 weeks\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"When did the clinical symptoms initially present? cannot be blank.\" data-invmsg=\"When did the clinical symptoms initially present? is invalid\"   \/> Within 2 weeks<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_290-281-3\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[290]\" id=\"field_f354t2-3\" value=\"2 \u2013 8 weeks post treatment\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"When did the clinical symptoms initially present? cannot be blank.\" data-invmsg=\"When did the clinical symptoms initially present? is invalid\"   \/> 2 \u2013 8 weeks post treatment<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_290-281-4\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[290]\" id=\"field_f354t2-4\" value=\"8 weeks to 1 year post treatment\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"When did the clinical symptoms initially present? cannot be blank.\" data-invmsg=\"When did the clinical symptoms initially present? is invalid\"   \/> 8 weeks to 1 year post treatment<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_290-281-5\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[290]\" id=\"field_f354t2-5\" value=\"More than 1 year post treatment\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"When did the clinical symptoms initially present? cannot be blank.\" data-invmsg=\"When did the clinical symptoms initially present? is invalid\"   \/> More than 1 year post treatment<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_290-281-6\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[290]\" id=\"field_f354t2-6\" value=\"Unknown \/ Unsure\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"When did the clinical symptoms initially present? cannot be blank.\" data-invmsg=\"When did the clinical symptoms initially present? is invalid\"   \/> Unknown \/ Unsure<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_290-281-other_5\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[290]\" id=\"field_f354t2-other_5\" value=\"Other\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"When did the clinical symptoms initially present? cannot be blank.\" data-invmsg=\"When did the clinical symptoms initially present? is invalid\"   \/> Other<\/label><label for=\"field_f354t2-other_5-otext\" class=\"frm_screen_reader frm_hidden\">Other<\/label><input type=\"text\" id=\"field_f354t2-other_5-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][290]\" value=\"\" \/><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_291_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_92ait\" id=\"field_92ait_label\" class=\"frm_primary_label\">Please provide further details relating to adverse event including timeline of events, symptoms implemented treatment.\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[291]\" id=\"field_92ait\" rows=\"5\"  data-sectionid=\"281\" data-invmsg=\"Please provide further details relating to adverse event including timeline of events, symptoms implemented treatment. is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_292_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_18llj\" id=\"field_18llj_label\" class=\"frm_primary_label\">Please provide the brand of medicine and\/or device, the batch\/lot number and expiry date (if known)\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_18llj\" name=\"item_meta[292]\" value=\"\"  data-sectionid=\"281\" data-invmsg=\"Please provide the brand of medicine and\/or device, the batch\/lot number and expiry date (if known) is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_293_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div id=\"field_he83l_label\" class=\"frm_primary_label\">Please select all treatment zones from below\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_293-281-0\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[293][]\" id=\"field_he83l-0\" value=\"Upper Face\"  data-sectionid=\"281\" data-reqmsg=\"Please select all treatment zones from below cannot be blank.\" data-invmsg=\"Please select all treatment zones from below is invalid\"   aria-required=\"true\"  \/> Upper Face<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_293-281-1\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[293][]\" id=\"field_he83l-1\" value=\"Mid Face\"  data-sectionid=\"281\" data-reqmsg=\"Please select all treatment zones from below cannot be blank.\" data-invmsg=\"Please select all treatment zones from below is invalid\"   \/> Mid Face<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_293-281-2\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[293][]\" id=\"field_he83l-2\" value=\"Lower Face\"  data-sectionid=\"281\" data-reqmsg=\"Please select all treatment zones from below cannot be blank.\" data-invmsg=\"Please select all treatment zones from below is invalid\"   \/> Lower Face<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_293-281-3\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[293][]\" id=\"field_he83l-3\" value=\"Body\"  data-sectionid=\"281\" data-reqmsg=\"Please select all treatment zones from below cannot be blank.\" data-invmsg=\"Please select all treatment zones from below is invalid\"   \/> Body<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_293-281-4\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[293][]\" id=\"field_he83l-4\" value=\"Other (please provide details in next question)\"  data-sectionid=\"281\" data-reqmsg=\"Please select all treatment zones from below cannot be blank.\" data-invmsg=\"Please select all treatment zones from below is invalid\"   \/> Other (please provide details in next question)<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_294_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio frm_other_container\">\r\n    <div id=\"field_q1y1i_label\" class=\"frm_primary_label\">Specific treatment area (please select all affected areas)\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-0\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-0\" value=\"Cerebrum\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   aria-required=\"true\"  \/> Cerebrum<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-1\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-1\" value=\"Scalp\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Scalp<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-2\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-2\" value=\"Eyelid\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Eyelid<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-3\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-3\" value=\"Forehead\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Forehead<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-4\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-4\" value=\"Temples\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Temples<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-5\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-5\" value=\"Intra-orbital (e.g. CRAO \/OAO)\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Intra-orbital (e.g. CRAO \/OAO)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-6\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-6\" value=\"Tear Trough\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Tear Trough<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-7\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-7\" value=\"Glabellar\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Glabellar<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-8\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-8\" value=\"Brow\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Brow<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-9\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-9\" value=\"Nose\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Nose<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-10\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-10\" value=\"Lateral cheek\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Lateral cheek<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-11\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-11\" value=\"Middle cheek\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Middle cheek<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-12\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-12\" value=\"Medial cheek\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Medial cheek<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-13\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-13\" value=\"Sub malar\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Sub malar<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-14\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-14\" value=\"Buccal hollows\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Buccal hollows<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-15\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-15\" value=\"Lips \u2013 Upper\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Lips \u2013 Upper<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-16\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-16\" value=\"Lips \u2013 Lower\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Lips \u2013 Lower<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-17\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-17\" value=\"Nasolabial \u2013 Line \/ wrinkle\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Nasolabial \u2013 Line \/ wrinkle<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-18\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-18\" value=\"Nasolabial - Piriform aperture\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Nasolabial - Piriform aperture<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-19\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-19\" value=\"Perioral (e.g. oral commissures, vertical lip lines, accordion lines)\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Perioral (e.g. oral commissures, vertical lip lines, accordion lines)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-20\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-20\" value=\"Intra-orla (including mucosa, tongue, teeth, gums, palate)\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Intra-orla (including mucosa, tongue, teeth, gums, palate)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-21\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-21\" value=\"Chin\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Chin<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-22\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-22\" value=\"Marionettes\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Marionettes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-23\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-23\" value=\"Pre jowl sulcus\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Pre jowl sulcus<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-24\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-24\" value=\"Jowl\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Jowl<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-25\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-25\" value=\"Jawline \u2013 anterior to facial artery\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Jawline \u2013 anterior to facial artery<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-26\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-26\" value=\"Jawline \u2013 posterior to facial artery\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Jawline \u2013 posterior to facial artery<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-27\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-27\" value=\"Pre-auricular\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Pre-auricular<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-28\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-28\" value=\"Sub mental\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Sub mental<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-29\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-29\" value=\"Body\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Body<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-30\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][]\" id=\"field_q1y1i-30\" value=\"Neck\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Neck<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_294-281-other_21\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[294][other_21]\" id=\"field_q1y1i-other_21\" value=\"Other\"  data-sectionid=\"281\" data-reqmsg=\"Specific treatment area (please select all affected areas) cannot be blank.\" data-invmsg=\"Specific treatment area (please select all affected areas) is invalid\"   \/> Other<\/label><label for=\"field_q1y1i-other_21-otext\" class=\"frm_screen_reader frm_hidden\">Other<\/label><input type=\"text\" id=\"field_q1y1i-other_21-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][294][other_21]\" value=\"\" \/><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_295_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div id=\"field_xopjc2_label\" class=\"frm_primary_label\">Technique used\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_295-281-0\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[295][]\" id=\"field_xopjc2-0\" value=\"Neelde\"  data-sectionid=\"281\" data-reqmsg=\"Technique used cannot be blank.\" data-invmsg=\"Technique used is invalid\"   aria-required=\"true\"  \/> Neelde<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_295-281-1\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[295][]\" id=\"field_xopjc2-1\" value=\"Cannula - 23g or larger\"  data-sectionid=\"281\" data-reqmsg=\"Technique used cannot be blank.\" data-invmsg=\"Technique used is invalid\"   \/> Cannula - 23g or larger<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_295-281-2\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[295][]\" id=\"field_xopjc2-2\" value=\"Cannula - 25g or smaller\"  data-sectionid=\"281\" data-reqmsg=\"Technique used cannot be blank.\" data-invmsg=\"Technique used is invalid\"   \/> Cannula - 25g or smaller<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_295-281-3\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[295][]\" id=\"field_xopjc2-3\" value=\"Both needle and cannula\"  data-sectionid=\"281\" data-reqmsg=\"Technique used cannot be blank.\" data-invmsg=\"Technique used is invalid\"   \/> Both needle and cannula<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_296_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div id=\"field_3bite2_label\" class=\"frm_primary_label\">Anatomical placement and depth of injection\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_296-281-0\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[296]\" id=\"field_3bite2-0\" value=\"Dermis\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"Anatomical placement and depth of injection cannot be blank.\" data-invmsg=\"Anatomical placement and depth of injection is invalid\"   \/> Dermis<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_296-281-1\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[296]\" id=\"field_3bite2-1\" value=\"Sub cutaneous\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"Anatomical placement and depth of injection cannot be blank.\" data-invmsg=\"Anatomical placement and depth of injection is invalid\"   \/> Sub cutaneous<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_296-281-2\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[296]\" id=\"field_3bite2-2\" value=\"Intra-muscular\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"Anatomical placement and depth of injection cannot be blank.\" data-invmsg=\"Anatomical placement and depth of injection is invalid\"   \/> Intra-muscular<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_296-281-3\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[296]\" id=\"field_3bite2-3\" value=\"Periosteum\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"Anatomical placement and depth of injection cannot be blank.\" data-invmsg=\"Anatomical placement and depth of injection is invalid\"   \/> Periosteum<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_296-281-4\">\t\t\t<label >\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[296]\" id=\"field_3bite2-4\" value=\"Periosteum and sub cutaneous\"\n\t\t data-sectionid=\"281\" data-reqmsg=\"Anatomical placement and depth of injection cannot be blank.\" data-invmsg=\"Anatomical placement and depth of injection is invalid\"   \/> Periosteum and sub cutaneous<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_297_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_g6yql\" id=\"field_g6yql_label\" class=\"frm_primary_label\">Total dose administered \r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_g6yql\" name=\"item_meta[297]\" value=\"\"  data-sectionid=\"281\" data-invmsg=\"Total dose administered  is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_298_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_etvlo\" id=\"field_etvlo_label\" class=\"frm_primary_label\">Please provide any other specific details relating to the treatment area or technique\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[298]\" id=\"field_etvlo\" rows=\"5\"  data-sectionid=\"281\" data-invmsg=\"Please provide any other specific details relating to the treatment area or technique is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_300_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_first\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Patient Details<\/h3>\r\n\r\n\r\n<div id=\"frm_field_301_container\" 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Drop a file here or click to upload. Maximum file size: 1.54MB\">Drop a file here or click to upload<\/button><\/span>\n\t\t<span class=\"frm_compact_text\"><button type=\"button\" aria-label=\"File Upload. Choose File. Maximum file size: 1.54MB\">Choose File<\/button><\/span>\n\t\t<div class=\"frm_small_text\">\n\t\t\t<p>Maximum file size: 1.54MB<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\t\r\n    \r\n    \r\n<\/div>\n<\/div>\n<input type=\"hidden\" name=\"item_meta[309]\" id=\"field_3benk\" value=\"\" data-frmval=\"\"\/>\n<div id=\"frm_field_310_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_gctlo\" id=\"field_gctlo_label\" class=\"frm_primary_label\">Triage\/Field Expert Comments\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[310]\" id=\"field_gctlo\" rows=\"5\"  placeholder=\"Please leave this section blank -To be completed  by an AMET Expert  \/ staff member.\" data-invmsg=\"Triage\/Field Expert Comments is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_311_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_f4uvn2\" id=\"field_f4uvn2_label\" class=\"frm_primary_label\">\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[311]\" id=\"field_f4uvn2\" rows=\"5\"  data-frmval=\"*The AMET nurse team will be notified via text message once this form is completed. We will respond via email within 24 hours; if in need of urgent assistance, contact AMA. AMET nurse email support service operates between AEST 8am-8pm Monday to Friday and 9am-5pm Saturday and Sunday.   If your request comes through outside business hours we will do our best to respond as soon as possible or within the next operating business hours. Please refer to adverse event protocols in the members only section on the AMET site able to be accessed 24\/7. Please do not delay care to your patient and these times are a guide. AMET needs the contact information you provide \u00a0to contact you about the reported adverse event. \u00a0You may unsubscribe from these communications at anytime. For information on how to unsubscribe, as well as our privacy practices and commitment to protecting your privacy, check out our Privacy Policy. Please note reporting the adverse event does not replace reporting to \u00a0TGA, pharmaceutical companies or any legal obligation as a health care practitioner. Please do not delay care for your patient by completeing this form. \u00a0Reporting of an adverse event is only to be captured by the treating HCP and \/ or prescribing practitioner whom has treated and or presribed the medicine to the patient experiencing the adverse event or is actively managing the adverse event. By reporting the adverse event you are consenting and confirming the patient has given consent to report, \u00a0upload file and images of the adverse event to AMET \u00a0and AMET will only use for support, complication management and internal educational purposes. If you have an active adverse event please manage as per your protocols and if you require assistance please contact AMET via this online form.\" data-invmsg=\"This field is invalid\" aria-invalid=\"false\"  >*The AMET nurse team will be notified via text message once this form is completed. We will respond via email within 24 hours; if in need of urgent assistance, contact AMA. AMET nurse email support service operates between AEST 8am-8pm Monday to Friday and 9am-5pm Saturday and Sunday.   If your request comes through outside business hours we will do our best to respond as soon as possible or within the next operating business hours. Please refer to adverse event protocols in the members only section on the AMET site able to be accessed 24\/7. Please do not delay care to your patient and these times are a guide. AMET needs the contact information you provide \u00a0to contact you about the reported adverse event. \u00a0You may unsubscribe from these communications at anytime. For information on how to unsubscribe, as well as our privacy practices and commitment to protecting your privacy, check out our Privacy Policy. Please note reporting the adverse event does not replace reporting to \u00a0TGA, pharmaceutical companies or any legal obligation as a health care practitioner. Please do not delay care for your patient by completeing this form. \u00a0Reporting of an adverse event is only to be captured by the treating HCP and \/ or prescribing practitioner whom has treated and or presribed the medicine to the patient experiencing the adverse event or is actively managing the adverse event. By reporting the adverse event you are consenting and confirming the patient has given consent to report, \u00a0upload file and images of the adverse event to AMET \u00a0and AMET will only use for support, complication management and internal educational purposes. If you have an active adverse event please manage as per your protocols and if you require assistance please contact AMET via this online form.\r\n<\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_312_container\" class=\"frm_form_field form-field\">\r\n\t<div class=\"frm_submit frm_flex\">\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"  formnovalidate=\"formnovalidate\">Submit<\/button>\r\n\r\n\r\n\r\n<\/div>\r\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_366_container\">\n\t\t\t<label for=\"field_epns6\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_epns6\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[366]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"x+\/sRINbjTCrSZ9QGRir8+b+tnZOuE6btbqnGopiTN541ja6XZj40b809tdvqi5w\" \/><\/div>\n<\/fieldset>\n<\/div>\n\n<input type=\"hidden\" name=\"trp-form-language\" value=\"en_au\"\/><\/form>\n<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>",
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