{"id":6501,"date":"2026-05-13T10:27:09","date_gmt":"2026-05-13T10:27:09","guid":{"rendered":"https:\/\/amlwpqa.alliancetek.net\/?page_id=6501"},"modified":"2026-06-18T19:49:12","modified_gmt":"2026-06-18T19:49:12","slug":"patient-billing","status":"publish","type":"page","link":"https:\/\/amlwpqa.alliancetek.net\/index.php\/patient-billing\/","title":{"rendered":"Patient Billing"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"6501\" class=\"elementor elementor-6501\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-9fa1c2c e-con-full e-flex e-con e-parent\" data-id=\"9fa1c2c\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-710b87a elementor-absolute dce_masking-none elementor-widget elementor-widget-image\" data-id=\"710b87a\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_position&quot;:&quot;absolute&quot;}\" data-widget_type=\"image.default\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"1920\" height=\"1920\" src=\"https:\/\/amlwpqa.alliancetek.net\/wp-content\/uploads\/2026\/03\/HEX-1-Primary-1-3.webp\" class=\"attachment-full size-full wp-image-1198\" alt=\"\" srcset=\"https:\/\/amlwpqa.alliancetek.net\/wp-content\/uploads\/2026\/03\/HEX-1-Primary-1-3.webp 1920w, https:\/\/amlwpqa.alliancetek.net\/wp-content\/uploads\/2026\/03\/HEX-1-Primary-1-3-300x300.webp 300w, https:\/\/amlwpqa.alliancetek.net\/wp-content\/uploads\/2026\/03\/HEX-1-Primary-1-3-1024x1024.webp 1024w, https:\/\/amlwpqa.alliancetek.net\/wp-content\/uploads\/2026\/03\/HEX-1-Primary-1-3-150x150.webp 150w, https:\/\/amlwpqa.alliancetek.net\/wp-content\/uploads\/2026\/03\/HEX-1-Primary-1-3-768x768.png 768w, https:\/\/amlwpqa.alliancetek.net\/wp-content\/uploads\/2026\/03\/HEX-1-Primary-1-3-1536x1536.png 1536w, https:\/\/amlwpqa.alliancetek.net\/wp-content\/uploads\/2026\/03\/HEX-1-Primary-1-3-2048x2048.png 2048w\" sizes=\"(max-width: 1920px) 100vw, 1920px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-a2533da e-con-full e-flex e-con e-child\" data-id=\"a2533da\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-c9dd22d e-con-full e-flex e-con e-child\" data-id=\"c9dd22d\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-68b8628 e-con-full e-flex e-con e-child\" data-id=\"68b8628\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3d24116 elementor-widget elementor-widget-breadcrumbs\" data-id=\"3d24116\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"breadcrumbs.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<span><span class=\"last\">Home<\/span><\/span>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-2330d09 e-con-full e-flex e-con e-child\" data-id=\"2330d09\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-475bfcb e-con-full e-flex e-con e-child\" data-id=\"475bfcb\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-33c8859 elementor-widget elementor-widget-text-editor\" data-id=\"33c8859\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>Patient Billing<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-428c463 elementor-widget__width-initial elementor-widget elementor-widget-text-editor\" data-id=\"428c463\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut viverra enim et libero viverra eleifend. In ornare sodales lorem, non semper lorem commodo sit amet. Proin imperdiet pretium egestas. Integer et lectus tristique, auctor enim a, lacinia mi. In suscipit lectus non ornare facilisis.\u00a0<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-708a050 e-con-full e-flex e-con e-parent\" data-id=\"708a050\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ef278bc elementor-widget__width-initial elementor-absolute dce_masking-none elementor-widget elementor-widget-image\" data-id=\"ef278bc\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_position&quot;:&quot;absolute&quot;}\" data-widget_type=\"image.default\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"1082\" height=\"1132\" src=\"https:\/\/amlwpqa.alliancetek.net\/wp-content\/uploads\/2026\/03\/HEX-1-Tirtiary-1.webp\" class=\"attachment-full size-full wp-image-1476\" alt=\"\" srcset=\"https:\/\/amlwpqa.alliancetek.net\/wp-content\/uploads\/2026\/03\/HEX-1-Tirtiary-1.webp 1082w, https:\/\/amlwpqa.alliancetek.net\/wp-content\/uploads\/2026\/03\/HEX-1-Tirtiary-1-287x300.webp 287w, https:\/\/amlwpqa.alliancetek.net\/wp-content\/uploads\/2026\/03\/HEX-1-Tirtiary-1-979x1024.webp 979w, https:\/\/amlwpqa.alliancetek.net\/wp-content\/uploads\/2026\/03\/HEX-1-Tirtiary-1-768x803.webp 768w\" sizes=\"(max-width: 1082px) 100vw, 1082px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-8e1f6f9 e-con-full e-flex e-con e-child\" data-id=\"8e1f6f9\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-86291bd e-con-full e-flex e-con e-child\" data-id=\"86291bd\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-16118dd elementor-widget elementor-widget-text-editor\" data-id=\"16118dd\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>Invoice<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-c9ff9cc e-con-full e-flex e-con e-child\" data-id=\"c9ff9cc\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-61bf27d elementor-widget__width-initial elementor-button-align-start payment-form-data elementor-widget elementor-widget-form\" data-id=\"61bf27d\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;label_icon_size&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:10,&quot;sizes&quot;:[]},&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;,&quot;field_icon_size&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]}}\" data-widget_type=\"form.default\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"New Form\" aria-label=\"New Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"6501\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"61bf27d\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Patient Billing - AccessMedLab\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"6501\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7f1b793 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7f1b793\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPatient's Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7f1b793]\" id=\"form-field-field_7f1b793\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Enter patient&#039;s name here\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_d502a42 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d502a42\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInvoice Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_d502a42]\" id=\"form-field-field_d502a42\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Enter invoice number here\" required=\"required\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_6d2f018 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6d2f018\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAmount\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_6d2f018]\" id=\"form-field-field_6d2f018\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Enter price price here\" required=\"required\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_325cc29 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_325cc29\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMessage\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[field_325cc29]\" id=\"form-field-field_325cc29\" rows=\"3\" placeholder=\"Enter price price here\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Add Invoice<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-57f92a9 e-con-full e-flex e-con e-child\" data-id=\"57f92a9\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-dbbf8a9 elementor-widget elementor-widget-text-editor\" data-id=\"dbbf8a9\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>All Invoices<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-f03dcd3 e-con-full e-flex e-con e-child\" data-id=\"f03dcd3\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-e129d4a e-con-full access-cart-item e-flex e-con e-child\" data-id=\"e129d4a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-de25fc2 e-con-full e-flex e-con e-child\" data-id=\"de25fc2\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-b4983b9 e-con-full e-flex e-con e-child\" data-id=\"b4983b9\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-653806e elementor-widget elementor-widget-heading\" data-id=\"653806e\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Dennis John Doe<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-4d37d94 elementor-widget elementor-widget-text-editor\" data-id=\"4d37d94\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut elit tellus, luctus nec ullamcorper mattis<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-c8cd663 e-con-full e-flex e-con e-child\" data-id=\"c8cd663\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ec835f1 elementor-widget elementor-widget-text-editor\" data-id=\"ec835f1\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>Invoice Number<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div data-dce-text-color=\"#191919\" class=\"elementor-element elementor-element-0d25949 elementor-widget elementor-widget-text-editor\" data-id=\"0d25949\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>#234567<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-e8a8b07 e-con-full e-flex e-con e-child\" data-id=\"e8a8b07\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div data-dce-title-color=\"#191919\" class=\"elementor-element elementor-element-b7d2879 elementor-widget elementor-widget-heading\" data-id=\"b7d2879\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">$197<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div data-dce-title-color=\"#FF0000\" class=\"elementor-element elementor-element-0fdd7f9 elementor-widget elementor-widget-heading\" data-id=\"0fdd7f9\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Remove<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-aa5c19a e-con-full e-flex e-con e-child\" data-id=\"aa5c19a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-011a471 elementor-widget elementor-widget-text-editor\" data-id=\"011a471\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>Payment<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-367327f e-con-full e-flex e-con e-child\" data-id=\"367327f\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-adf58ef elementor-widget elementor-widget-html\" data-id=\"adf58ef\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t\t<div class=\"access-custom-card-wrapper payment-field-group\">\r\n    <label class=\"custom-field-label\">Card Number<\/label>\r\n    <div class=\"input-icon-container\">\r\n        <input type=\"text\" \r\n               id=\"custom-card-number\" \r\n               placeholder=\"0000 0000 0000 0000\" \r\n               maxlength=\"19\"\r\n               class=\"access-input-field\">\r\n        <div class=\"card-icons-rows\">\r\n            <img decoding=\"async\" src=\"https:\/\/amlwpqa.alliancetek.net\/wp-content\/uploads\/2026\/04\/logos_amex.png\" alt=\"Visa\">\r\n            <img decoding=\"async\" src=\"https:\/\/amlwpqa.alliancetek.net\/wp-content\/uploads\/2026\/04\/logos_mastercard.png\" alt=\"Mastercard\">\r\n            <img decoding=\"async\" src=\"https:\/\/amlwpqa.alliancetek.net\/wp-content\/uploads\/2026\/04\/Page-1.png\" alt=\"Amex\">\r\n            <img decoding=\"async\" src=\"https:\/\/amlwpqa.alliancetek.net\/wp-content\/uploads\/2026\/04\/logos_visaelectron.png\" alt=\"Discover\">\r\n        <\/div>\r\n    <\/div>\r\n<\/div>\r\n\r\n<style>\r\n\/* MATCHING ELEMENTOR FIELD STYLES *\/\r\n.access-custom-card-wrapper {\r\n    display: flex;\r\n    flex-direction: column;\r\n    gap: 8px; \/* Your design's 8px label spacing *\/\r\n    width: 100%;\r\n}\r\n\r\n.custom-field-label {\r\n    font-family: 'Proxima Nova', sans-serif;\r\n    font-weight: 400;\r\n    font-size: 18px;\r\n    color: #333333;\r\n}\r\n\r\n.input-icon-container {\r\n    position: relative;\r\n    display: flex;\r\n    align-items: center;\r\n}\r\n\r\n.access-input-field {\r\n    width: 100%;\r\n    height: 50px; \/* Match your Elementor field height *\/\r\n    padding: 10px 130px 10px 15px !important;\r\n    border: 0.5px solid #8080805C !important;\r\n    border-radius: 10000px !important;\r\n    font-family: 'Proxima Nova', sans-serif;\r\n    font-size: 16px;\r\n    outline: none;\r\n    transition: border-color 0.2s;\r\n}\r\n\r\n.access-input-field:focus {\r\n    border: 2px solid !important;\r\n    border-color: #8080805C !important;\r\n    transition: border-color 0.2s;\r\n}\r\n\r\n\/* --- PLACEHOLDER STYLING --- *\/\r\n.access-input-field::placeholder {\r\n    font-size: 17px !important;\r\n    font-weight: 300 !important;\r\n    color: #CCCCCC !important;\r\n    opacity: 0.6 !important;\r\n    font-family: 'Proxima Nova', sans-serif;\r\n}\r\n\r\n\/* For Safari\/Chrome *\/\r\n.access-input-field::-webkit-input-placeholder {\r\n    font-size: 17px !important;\r\n    font-weight: 300 !important;\r\n    color: #CCCCCC !important;\r\n    opacity: 0.6 !important;\r\n}\r\n\r\n\/* --- ICON ROW STYLING --- *\/\r\n.card-icons-rows {\r\n    position: absolute!important;\r\n    right: 15px;\r\n    top: 50% !important;\r\n    transform: translateY(-50%) !important;\r\n    display: flex;\r\n    flex-direction: row !important;\r\n    align-items: center !important;\r\n    gap: 10px !important;\r\n    pointer-events: none;\r\n    width: auto;\r\n    height: 100% !important; \/* Container matches input height *\/\r\n    max-width: none !important; \/* Keeps them from pushing too far left *\/\r\n    overflow: hidden !important;\r\n}\r\n\r\n.card-icons-rows img {\r\n    height: 22px !important; \/* Adjust height to match design *\/\r\n    width: auto !important;\r\n    object-fit: contain;\r\n    display: inline-block !important;\r\n    flex-shrink: 0 !important;\r\n}\r\n<\/style>\r\n\r\n<script>\r\n\/\/ AUTO-SPACING LOGIC (e.g., 4444 4444...)\r\ndocument.getElementById('custom-card-number').addEventListener('input', function (e) {\r\n    let target = e.target;\r\n    let position = target.selectionEnd;\r\n    let length = target.value.length;\r\n    \r\n    \/\/ Remove all non-digits\r\n    let value = target.value.replace(\/\\D\/g, '');\r\n    \/\/ Add space every 4 digits\r\n    let formatted = value.replace(\/(.{4})\/g, '$1 ').trim();\r\n    \r\n    target.value = formatted;\r\n    \r\n    \/\/ Maintain cursor position\r\n    if (length !== target.value.length && position !== length) {\r\n        target.setSelectionRange(position + 1, position + 1);\r\n    }\r\n});\r\n<\/script>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-47eb8fa elementor-widget__width-initial elementor-button-align-start payment-form-data elementor-widget elementor-widget-form\" data-id=\"47eb8fa\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;label_icon_size&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:10,&quot;sizes&quot;:[]},&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;,&quot;field_icon_size&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]}}\" data-widget_type=\"form.default\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"New Form\" aria-label=\"New Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"6501\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"47eb8fa\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Patient Billing - AccessMedLab\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"6501\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_7f1b793 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7f1b793\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmail\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_7f1b793]\" id=\"form-field-field_7f1b793\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Enter email address here\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d502a42 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d502a42\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCard Holder Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d502a42]\" id=\"form-field-field_d502a42\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Enter card holder name here\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_eb601a2 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_eb601a2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCVV\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_eb601a2]\" id=\"form-field-field_eb601a2\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Enter cvv digits here\" required=\"required\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_3949691 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3949691\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tExpiry Date\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_3949691]\" id=\"form-field-field_3949691\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field\" placeholder=\"MM\/YYY\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_6d2f018 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6d2f018\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_6d2f018]\" id=\"form-field-field_6d2f018\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Enter house address here\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f7afdf7 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f7afdf7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBilling Zip\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f7afdf7]\" id=\"form-field-field_f7afdf7\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Enter Billing Code here\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-dce_form_country elementor-field-group elementor-column elementor-field-group-field_dabdaf2 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dabdaf2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCountry\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper \">\n\t\t\t<select name=\"form_fields[field_dabdaf2]\" id=\"form-field-field_dabdaf2\" class=\"elementor-field-textual elementor-size-md\" data-dce-country-field=\"true\" data-dce-country-placeholder=\"Select a country\" data-dce-no-select2=\"\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t<option value=\"\">Select a country<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"US\" >\n\t\t\t\t\t\tUnited States\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AF\" >\n\t\t\t\t\t\tAfghanistan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AX\" >\n\t\t\t\t\t\tAland Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AL\" >\n\t\t\t\t\t\tAlbania\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DZ\" >\n\t\t\t\t\t\tAlgeria\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AS\" >\n\t\t\t\t\t\tAmerican Samoa\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AD\" >\n\t\t\t\t\t\tAndorra\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AO\" >\n\t\t\t\t\t\tAngola\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AI\" >\n\t\t\t\t\t\tAnguilla\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AQ\" >\n\t\t\t\t\t\tAntarctica\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AG\" >\n\t\t\t\t\t\tAntigua And Barbuda\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AR\" >\n\t\t\t\t\t\tArgentina\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AM\" >\n\t\t\t\t\t\tArmenia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AW\" >\n\t\t\t\t\t\tAruba\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AU\" >\n\t\t\t\t\t\tAustralia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AT\" >\n\t\t\t\t\t\tAustria\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AZ\" >\n\t\t\t\t\t\tAzerbaijan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BS\" >\n\t\t\t\t\t\tBahamas\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BH\" >\n\t\t\t\t\t\tBahrain\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BD\" >\n\t\t\t\t\t\tBangladesh\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BB\" >\n\t\t\t\t\t\tBarbados\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BY\" >\n\t\t\t\t\t\tBelarus\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BE\" >\n\t\t\t\t\t\tBelgium\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BZ\" >\n\t\t\t\t\t\tBelize\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BJ\" >\n\t\t\t\t\t\tBenin\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BM\" >\n\t\t\t\t\t\tBermuda\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BT\" >\n\t\t\t\t\t\tBhutan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BO\" >\n\t\t\t\t\t\tBolivia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BA\" >\n\t\t\t\t\t\tBosnia And Herzegovina\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BW\" >\n\t\t\t\t\t\tBotswana\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BV\" >\n\t\t\t\t\t\tBouvet Island\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BR\" >\n\t\t\t\t\t\tBrazil\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IO\" >\n\t\t\t\t\t\tBritish Indian Ocean Territory\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BN\" >\n\t\t\t\t\t\tBrunei Darussalam\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BQ\" >\n\t\t\t\t\t\tBonaire, Sint Eustatius and Saba\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BG\" >\n\t\t\t\t\t\tBulgaria\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BF\" >\n\t\t\t\t\t\tBurkina Faso\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BI\" >\n\t\t\t\t\t\tBurundi\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KH\" >\n\t\t\t\t\t\tCambodia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CM\" >\n\t\t\t\t\t\tCameroon\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CA\" >\n\t\t\t\t\t\tCanada\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CV\" >\n\t\t\t\t\t\tCape Verde\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KY\" >\n\t\t\t\t\t\tCayman Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CF\" >\n\t\t\t\t\t\tCentral African Republic\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TD\" >\n\t\t\t\t\t\tChad\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CL\" >\n\t\t\t\t\t\tChile\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CN\" >\n\t\t\t\t\t\tChina\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CX\" >\n\t\t\t\t\t\tChristmas Island\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CC\" >\n\t\t\t\t\t\tCocos (Keeling) Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CO\" >\n\t\t\t\t\t\tColombia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KM\" >\n\t\t\t\t\t\tComoros\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CG\" >\n\t\t\t\t\t\tCongo\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CD\" >\n\t\t\t\t\t\tCongo, Democratic Republic\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CK\" >\n\t\t\t\t\t\tCook Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CR\" >\n\t\t\t\t\t\tCosta Rica\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CI\" >\n\t\t\t\t\t\tCote D&#039;Ivoire\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HR\" >\n\t\t\t\t\t\tCroatia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CU\" >\n\t\t\t\t\t\tCuba\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CW\" >\n\t\t\t\t\t\tCura\u00e7ao\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CY\" >\n\t\t\t\t\t\tCyprus\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CZ\" >\n\t\t\t\t\t\tCzech Republic\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DK\" >\n\t\t\t\t\t\tDenmark\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DJ\" >\n\t\t\t\t\t\tDjibouti\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DM\" >\n\t\t\t\t\t\tDominica\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DO\" >\n\t\t\t\t\t\tDominican Republic\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EC\" >\n\t\t\t\t\t\tEcuador\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EG\" >\n\t\t\t\t\t\tEgypt\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SV\" >\n\t\t\t\t\t\tEl Salvador\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GQ\" >\n\t\t\t\t\t\tEquatorial Guinea\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ER\" >\n\t\t\t\t\t\tEritrea\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EE\" >\n\t\t\t\t\t\tEstonia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ET\" >\n\t\t\t\t\t\tEthiopia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FK\" >\n\t\t\t\t\t\tFalkland Islands (Malvinas)\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FO\" >\n\t\t\t\t\t\tFaroe Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FJ\" >\n\t\t\t\t\t\tFiji\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FI\" >\n\t\t\t\t\t\tFinland\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FR\" >\n\t\t\t\t\t\tFrance\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GF\" >\n\t\t\t\t\t\tFrench Guiana\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PF\" >\n\t\t\t\t\t\tFrench Polynesia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TF\" >\n\t\t\t\t\t\tFrench Southern Territories\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GA\" >\n\t\t\t\t\t\tGabon\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GM\" >\n\t\t\t\t\t\tGambia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GE\" >\n\t\t\t\t\t\tGeorgia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DE\" >\n\t\t\t\t\t\tGermany\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GH\" >\n\t\t\t\t\t\tGhana\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GI\" >\n\t\t\t\t\t\tGibraltar\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GR\" >\n\t\t\t\t\t\tGreece\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GL\" >\n\t\t\t\t\t\tGreenland\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GD\" >\n\t\t\t\t\t\tGrenada\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GP\" >\n\t\t\t\t\t\tGuadeloupe\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GU\" >\n\t\t\t\t\t\tGuam\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GT\" >\n\t\t\t\t\t\tGuatemala\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GG\" >\n\t\t\t\t\t\tGuernsey\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GN\" >\n\t\t\t\t\t\tGuinea\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GW\" >\n\t\t\t\t\t\tGuinea-Bissau\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GY\" >\n\t\t\t\t\t\tGuyana\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HT\" >\n\t\t\t\t\t\tHaiti\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HM\" >\n\t\t\t\t\t\tHeard Island &amp; Mcdonald Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VA\" >\n\t\t\t\t\t\tHoly See (Vatican City State)\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HN\" >\n\t\t\t\t\t\tHonduras\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HK\" >\n\t\t\t\t\t\tHong Kong\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HU\" >\n\t\t\t\t\t\tHungary\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IS\" >\n\t\t\t\t\t\tIceland\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IN\" >\n\t\t\t\t\t\tIndia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ID\" >\n\t\t\t\t\t\tIndonesia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IR\" >\n\t\t\t\t\t\tIran, Islamic Republic Of\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IQ\" >\n\t\t\t\t\t\tIraq\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IE\" >\n\t\t\t\t\t\tIreland\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IM\" >\n\t\t\t\t\t\tIsle Of Man\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IL\" >\n\t\t\t\t\t\tIsrael\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IT\" >\n\t\t\t\t\t\tItaly\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JM\" >\n\t\t\t\t\t\tJamaica\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JP\" >\n\t\t\t\t\t\tJapan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JE\" >\n\t\t\t\t\t\tJersey\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JO\" >\n\t\t\t\t\t\tJordan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KZ\" >\n\t\t\t\t\t\tKazakhstan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KE\" >\n\t\t\t\t\t\tKenya\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KI\" >\n\t\t\t\t\t\tKiribati\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KR\" >\n\t\t\t\t\t\tKorea\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KW\" >\n\t\t\t\t\t\tKuwait\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KG\" >\n\t\t\t\t\t\tKyrgyzstan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LA\" >\n\t\t\t\t\t\tLao People&#039;s Democratic Republic\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LV\" >\n\t\t\t\t\t\tLatvia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LB\" >\n\t\t\t\t\t\tLebanon\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LS\" >\n\t\t\t\t\t\tLesotho\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LR\" >\n\t\t\t\t\t\tLiberia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LY\" >\n\t\t\t\t\t\tLibyan Arab Jamahiriya\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LI\" >\n\t\t\t\t\t\tLiechtenstein\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LT\" >\n\t\t\t\t\t\tLithuania\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LU\" >\n\t\t\t\t\t\tLuxembourg\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MO\" >\n\t\t\t\t\t\tMacao\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MK\" >\n\t\t\t\t\t\tMacedonia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MG\" >\n\t\t\t\t\t\tMadagascar\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MW\" >\n\t\t\t\t\t\tMalawi\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MY\" >\n\t\t\t\t\t\tMalaysia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MV\" >\n\t\t\t\t\t\tMaldives\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ML\" >\n\t\t\t\t\t\tMali\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MT\" >\n\t\t\t\t\t\tMalta\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MH\" >\n\t\t\t\t\t\tMarshall Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MQ\" >\n\t\t\t\t\t\tMartinique\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MR\" >\n\t\t\t\t\t\tMauritania\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MU\" >\n\t\t\t\t\t\tMauritius\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"YT\" >\n\t\t\t\t\t\tMayotte\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MX\" >\n\t\t\t\t\t\tMexico\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FM\" >\n\t\t\t\t\t\tMicronesia, Federated States Of\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MD\" >\n\t\t\t\t\t\tMoldova\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MC\" >\n\t\t\t\t\t\tMonaco\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MN\" >\n\t\t\t\t\t\tMongolia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ME\" >\n\t\t\t\t\t\tMontenegro\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MS\" >\n\t\t\t\t\t\tMontserrat\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MA\" >\n\t\t\t\t\t\tMorocco\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MZ\" >\n\t\t\t\t\t\tMozambique\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MM\" >\n\t\t\t\t\t\tMyanmar\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NA\" >\n\t\t\t\t\t\tNamibia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NR\" >\n\t\t\t\t\t\tNauru\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NP\" >\n\t\t\t\t\t\tNepal\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NL\" >\n\t\t\t\t\t\tNetherlands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AN\" >\n\t\t\t\t\t\tNetherlands Antilles\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NC\" >\n\t\t\t\t\t\tNew Caledonia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NZ\" >\n\t\t\t\t\t\tNew Zealand\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NI\" >\n\t\t\t\t\t\tNicaragua\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NE\" >\n\t\t\t\t\t\tNiger\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NG\" >\n\t\t\t\t\t\tNigeria\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NU\" >\n\t\t\t\t\t\tNiue\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NF\" >\n\t\t\t\t\t\tNorfolk Island\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MP\" >\n\t\t\t\t\t\tNorthern Mariana Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NO\" >\n\t\t\t\t\t\tNorway\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OM\" >\n\t\t\t\t\t\tOman\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PK\" >\n\t\t\t\t\t\tPakistan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PW\" >\n\t\t\t\t\t\tPalau\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PS\" >\n\t\t\t\t\t\tPalestinian Territory, Occupied\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PA\" >\n\t\t\t\t\t\tPanama\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PG\" >\n\t\t\t\t\t\tPapua New Guinea\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PY\" >\n\t\t\t\t\t\tParaguay\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PE\" >\n\t\t\t\t\t\tPeru\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PH\" >\n\t\t\t\t\t\tPhilippines\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PN\" >\n\t\t\t\t\t\tPitcairn\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PL\" >\n\t\t\t\t\t\tPoland\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PT\" >\n\t\t\t\t\t\tPortugal\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PR\" >\n\t\t\t\t\t\tPuerto Rico\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"QA\" >\n\t\t\t\t\t\tQatar\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RE\" >\n\t\t\t\t\t\tReunion\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RO\" >\n\t\t\t\t\t\tRomania\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RU\" >\n\t\t\t\t\t\tRussian Federation\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RW\" >\n\t\t\t\t\t\tRwanda\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BL\" >\n\t\t\t\t\t\tSaint Barthelemy\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SH\" >\n\t\t\t\t\t\tSaint Helena\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KN\" >\n\t\t\t\t\t\tSaint Kitts And Nevis\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LC\" >\n\t\t\t\t\t\tSaint Lucia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MF\" >\n\t\t\t\t\t\tSaint Martin\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PM\" >\n\t\t\t\t\t\tSaint Pierre And Miquelon\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VC\" >\n\t\t\t\t\t\tSaint Vincent And Grenadines\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WS\" >\n\t\t\t\t\t\tSamoa\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SM\" >\n\t\t\t\t\t\tSan Marino\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ST\" >\n\t\t\t\t\t\tSao Tome And Principe\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SA\" >\n\t\t\t\t\t\tSaudi Arabia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SN\" >\n\t\t\t\t\t\tSenegal\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RS\" >\n\t\t\t\t\t\tSerbia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SC\" >\n\t\t\t\t\t\tSeychelles\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SL\" >\n\t\t\t\t\t\tSierra Leone\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SG\" >\n\t\t\t\t\t\tSingapore\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SX\" >\n\t\t\t\t\t\tSint Maarten\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SK\" >\n\t\t\t\t\t\tSlovakia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SI\" >\n\t\t\t\t\t\tSlovenia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SB\" >\n\t\t\t\t\t\tSolomon Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SO\" >\n\t\t\t\t\t\tSomalia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SS\" >\n\t\t\t\t\t\tSouth Sudan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZA\" >\n\t\t\t\t\t\tSouth Africa\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GS\" >\n\t\t\t\t\t\tSouth Georgia And Sandwich Isl.\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ES\" >\n\t\t\t\t\t\tSpain\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LK\" >\n\t\t\t\t\t\tSri Lanka\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SD\" >\n\t\t\t\t\t\tSudan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SR\" >\n\t\t\t\t\t\tSuriname\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SJ\" >\n\t\t\t\t\t\tSvalbard And Jan Mayen\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SZ\" >\n\t\t\t\t\t\tSwaziland\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SE\" >\n\t\t\t\t\t\tSweden\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CH\" >\n\t\t\t\t\t\tSwitzerland\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SY\" >\n\t\t\t\t\t\tSyrian Arab Republic\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TW\" >\n\t\t\t\t\t\tTaiwan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TJ\" >\n\t\t\t\t\t\tTajikistan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TZ\" >\n\t\t\t\t\t\tTanzania\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TH\" >\n\t\t\t\t\t\tThailand\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TL\" >\n\t\t\t\t\t\tTimor-Leste\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TG\" >\n\t\t\t\t\t\tTogo\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TK\" >\n\t\t\t\t\t\tTokelau\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TO\" >\n\t\t\t\t\t\tTonga\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TT\" >\n\t\t\t\t\t\tTrinidad And Tobago\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TN\" >\n\t\t\t\t\t\tTunisia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TR\" >\n\t\t\t\t\t\tTurkey\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TM\" >\n\t\t\t\t\t\tTurkmenistan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TC\" >\n\t\t\t\t\t\tTurks And Caicos Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TV\" >\n\t\t\t\t\t\tTuvalu\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UG\" >\n\t\t\t\t\t\tUganda\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UA\" >\n\t\t\t\t\t\tUkraine\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AE\" >\n\t\t\t\t\t\tUnited Arab Emirates\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GB\" >\n\t\t\t\t\t\tUnited Kingdom\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UM\" >\n\t\t\t\t\t\tUnited States Outlying Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UY\" >\n\t\t\t\t\t\tUruguay\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UZ\" >\n\t\t\t\t\t\tUzbekistan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VU\" >\n\t\t\t\t\t\tVanuatu\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VE\" >\n\t\t\t\t\t\tVenezuela\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VN\" >\n\t\t\t\t\t\tViet Nam\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"XK\" >\n\t\t\t\t\t\tKosovo\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VG\" >\n\t\t\t\t\t\tVirgin Islands, British\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VI\" >\n\t\t\t\t\t\tVirgin Islands, U.S.\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WF\" >\n\t\t\t\t\t\tWallis And Futuna\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EH\" >\n\t\t\t\t\t\tWestern Sahara\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"YE\" >\n\t\t\t\t\t\tYemen\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZM\" >\n\t\t\t\t\t\tZambia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZW\" >\n\t\t\t\t\t\tZimbabwe\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_6de1e9e elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6de1e9e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tState\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_6de1e9e]\" id=\"form-field-field_6de1e9e\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select a State\">Select a State<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"State 1\">State 1<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"State 2\">State 2<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"State 3\">State 3<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"State 4\">State 4<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"State 5\">State 5<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"State 6\">State 6<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"State 7\">State 7<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"State 8\">State 8<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"State 9\">State 9<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"State 10\">State 10<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_eff6b23 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_eff6b23\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCity\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_eff6b23]\" id=\"form-field-field_eff6b23\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Enter name of city here\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-recaptcha_v3 elementor-field-group elementor-column elementor-field-group-field_616bc95 elementor-col-100 recaptcha_v3-inline\">\n\t\t\t\t\t<div class=\"elementor-field\" id=\"form-field-field_616bc95\"><div class=\"elementor-g-recaptcha\" data-sitekey=\"6LfU-rYsAAAAALlpDAmxH-whw5l3lCbjoYg99A-D\" data-type=\"v3\" data-action=\"Form\" data-badge=\"inline\" data-size=\"invisible\"><\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Submit<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-471d0e3 e-con-full e-flex e-con e-child\" data-id=\"471d0e3\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div data-dce-text-color=\"#EF5C3F\" class=\"elementor-element elementor-element-4ddff12 elementor-widget elementor-widget-text-editor\" data-id=\"4ddff12\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>*3% TRANSACTION FEE ADDED ON ALL INVOICES<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-8c51c2f e-con-full e-flex e-con e-child\" data-id=\"8c51c2f\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ff061c8 elementor-widget elementor-widget-text-editor\" data-id=\"ff061c8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>Total Amount<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-00ed92e elementor-widget elementor-widget-text-editor\" data-id=\"00ed92e\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>$0.00<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Home Patient Billing Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut viverra enim et libero viverra eleifend. In ornare sodales lorem, non semper lorem commodo sit amet. Proin imperdiet pretium egestas. Integer et lectus tristique, auctor enim a, lacinia mi. In suscipit lectus non ornare facilisis.\u00a0 Invoice All Invoices Dennis John Doe Lorem ipsum [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"content-type":"","footnotes":""},"class_list":["post-6501","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/amlwpqa.alliancetek.net\/index.php\/wp-json\/wp\/v2\/pages\/6501","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/amlwpqa.alliancetek.net\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/amlwpqa.alliancetek.net\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/amlwpqa.alliancetek.net\/index.php\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/amlwpqa.alliancetek.net\/index.php\/wp-json\/wp\/v2\/comments?post=6501"}],"version-history":[{"count":172,"href":"https:\/\/amlwpqa.alliancetek.net\/index.php\/wp-json\/wp\/v2\/pages\/6501\/revisions"}],"predecessor-version":[{"id":8504,"href":"https:\/\/amlwpqa.alliancetek.net\/index.php\/wp-json\/wp\/v2\/pages\/6501\/revisions\/8504"}],"wp:attachment":[{"href":"https:\/\/amlwpqa.alliancetek.net\/index.php\/wp-json\/wp\/v2\/media?parent=6501"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}