{"id":7574,"date":"2024-11-14T12:55:32","date_gmt":"2024-11-14T11:55:32","guid":{"rendered":"https:\/\/1818-1.pm-domains.de\/contact\/"},"modified":"2026-05-06T10:55:32","modified_gmt":"2026-05-06T08:55:32","slug":"contact","status":"publish","type":"page","link":"https:\/\/alpstein-clinic.ch\/en\/contact\/","title":{"rendered":"Contact"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"7574\" class=\"elementor elementor-7574 elementor-572\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3efc5b3 e-con-full e-flex e-con e-parent\" data-id=\"3efc5b3\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[],&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-e44b7d9 elementor-widget elementor-widget-spacer\" data-id=\"e44b7d9\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-f4cb5dd e-flex e-con-boxed e-con e-parent\" data-id=\"f4cb5dd\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-e377f4f elementor-mobile-align-center elementor-widget-mobile__width-inherit elementor-absolute elementor-widget elementor-widget-breadcrumbs\" data-id=\"e377f4f\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_position&quot;:&quot;absolute&quot;}\" data-widget_type=\"breadcrumbs.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p id=\"breadcrumbs\">\t<i aria-hidden=\"true\" class=\"alpstein alpstein-Home\"><\/i>\n<span><span><a href=\"https:\/\/alpstein-clinic.ch\/en\/\">Startseite<\/a><\/span><\/span><\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6a3610f elementor-widget elementor-widget-jet-headline\" data-id=\"6a3610f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"jet-headline.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"jet-headline jet-headline--direction-vertical\"><span class=\"jet-headline__part jet-headline__first\"><span class=\"jet-headline__label\">Contact<\/span><\/span><\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-f750b51 elementor-widget elementor-widget-menu-anchor\" data-id=\"f750b51\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"menu-anchor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-menu-anchor\" id=\"kontaktformular\"><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-90737dc e-con-full e-flex e-con e-parent\" data-id=\"90737dc\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t<div class=\"elementor-element elementor-element-49289f3 e-flex e-con-boxed e-con e-child\" data-id=\"49289f3\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[],&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-32af31f e-con-full blurry e-flex e-con e-child\" data-id=\"32af31f\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3bb7253 elementor-widget elementor-widget-jet-headline\" data-id=\"3bb7253\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"jet-headline.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"jet-headline jet-headline--direction-horizontal\"><span class=\"jet-headline__part jet-headline__first\"><span class=\"jet-headline__label\">Do you have<\/span><\/span><span class=\"jet-headline__part jet-headline__second\"><span class=\"jet-headline__label\">&nbsp;any questions?<\/span><\/span><\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b04c2ec elementor-widget elementor-widget-spacer\" data-id=\"b04c2ec\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-5fa9cba elementor-hidden-mobile elementor-widget elementor-widget-text-editor\" data-id=\"5fa9cba\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p class=\"p1\">Call us on <a href=\"tel:+41717918100\">+41 71 791 81 00<\/a> and we will be happy to help you &#8211; or use our contact form.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-f19fdd1 elementor-hidden-widescreen elementor-hidden-desktop elementor-hidden-laptop elementor-hidden-tablet elementor-widget elementor-widget-text-editor\" data-id=\"f19fdd1\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p class=\"p1\">Call us on<\/p><p class=\"p1\"><a href=\"tel:+41717918100\">+41 71 791 81 00<\/a> and we will be happy to help you &#8211; or use our contact form.<\/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 class=\"elementor-element elementor-element-d79d8ea elementor-hidden-tablet elementor-hidden-mobile elementor-widget elementor-widget-spacer\" data-id=\"d79d8ea\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-fef132b e-con-full blurry elementor-hidden-tablet elementor-hidden-mobile e-flex e-con e-child\" data-id=\"fef132b\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ae6fa7e elementor-widget elementor-widget-jet-headline\" data-id=\"ae6fa7e\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"jet-headline.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p class=\"jet-headline jet-headline--direction-horizontal\"><span class=\"jet-headline__part jet-headline__first\"><span class=\"jet-headline__label\">Would you like to go<\/span><\/span><span class=\"jet-headline__part jet-headline__second\"><span class=\"jet-headline__label\">&nbsp;one step further?<\/span><\/span><\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-8d0489b elementor-widget elementor-widget-spacer\" data-id=\"8d0489b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2d5c561 elementor-widget elementor-widget-text-editor\" data-id=\"2d5c561\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p class=\"p1\">Then we offer you the opportunity to complete our patient questionnaire online.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-89a4c6f elementor-widget elementor-widget-spacer\" data-id=\"89a4c6f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-78527de elementor-widget__width-auto elementor-align-center elementor-widget elementor-widget-button\" data-id=\"78527de\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm elementor-animation-shrink\" href=\"#fragebogen\" aria-label=\"Zum Patientenfragebogen\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"alpstein alpstein-Pfeil-rechts\"><\/i>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">To the patient questionnaire<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\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\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-b93e66a e-flex e-con-boxed e-con e-child\" data-id=\"b93e66a\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[],&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3f9337f elementor-widget__width-inherit elementor-widget elementor-widget-jet-headline\" data-id=\"3f9337f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"jet-headline.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p class=\"jet-headline jet-headline--direction-horizontal\"><span class=\"jet-headline__part jet-headline__first\"><span class=\"jet-headline__label\">Contact<\/span><\/span><span class=\"jet-headline__part jet-headline__second\"><span class=\"jet-headline__label\">formular<\/span><\/span><\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-cf17e71 elementor-widget elementor-widget-spacer\" data-id=\"cf17e71\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0edc71f elementor-button-align-end elementor-widget-mobile__width-initial elementor-widget elementor-widget-form\" data-id=\"0edc71f\" 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;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"Contact form\" aria-label=\"Contact form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"7574\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"0edc71f\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Alpstein Clinic\" \/>\n\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-radio elementor-field-group elementor-column elementor-field-group-anrede elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-anrede\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSalutation\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Mr. &lt;br&gt;Mrs.\" id=\"form-field-anrede-0\" name=\"form_fields[anrede]\"> <label for=\"form-field-anrede-0\">Mr. <br>Mrs.<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Divers\" id=\"form-field-anrede-1\" name=\"form_fields[anrede]\"> <label for=\"form-field-anrede-1\">Divers<\/label><\/span><\/div>\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-name elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName*\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[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" 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-email elementor-field-group elementor-column elementor-field-group-email elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tE-mail address*\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[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" 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-telefon elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-telefon\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone\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[telefon]\" id=\"form-field-telefon\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-select elementor-field-group elementor-column elementor-field-group-interesse elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-interesse\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tI am interested in\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<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[interesse]\" id=\"form-field-interesse\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"-- Please select --\">-- Please select --<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Alpstein Medical\">Alpstein Medical<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Alpstein Dental\">Alpstein Dental<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Prevention\">Prevention<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"INUSpheresis\u00ae\">INUSpheresis\u00ae<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/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-textarea elementor-field-group elementor-column elementor-field-group-Nachricht elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-Nachricht\" 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-sm\" name=\"form_fields[Nachricht]\" id=\"form-field-Nachricht\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_34efe0f elementor-col-100\">\n\t\t\t\t\t* = required field\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-datenschutz elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[datenschutz]\" id=\"form-field-datenschutz\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-datenschutz\">I have read the <a href=\"https:\/\/alpstein-clinic.ch\/en\/data-protection\/\">privacy policy<\/a> and agree that my details and data will be collected and stored electronically to answer my enquiry.<br><strong>Note:<\/strong> You can revoke your consent at any time for the future by sending an e-mail to <a href=\"mailto:info@alpstein-clinic.ch\">info@alpstein-clinic.ch<\/a>.<\/label>\t\t\t<\/span>\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-coolcaptcha elementor-field-group elementor-column elementor-field-group-hcaptcha elementor-col-100\">\n\t\t\t\t\t    <input\n\ttype=\"hidden\"\n\tvalue=\"ccgo\"\n\tname=\"form_fields[hcaptcha]\"\n\t\tid=\"form-field-hcaptcha\"\n\t\t\tclass=\"elementor-field elementor-size-sm  elementor-field-textual\"\n\t    \/>\n<script type=text\/javascript src=\"https:\/\/magic.cool-captcha.de\/api.js?key=FPXXAO0I-UZWT48UH-BARAAQLF-TDQD4X2Y\"><\/script>\n<script>\nwindow.setTimeout(function(){\nvar t = [];\njQuery('input[name^=\"cctoken_\"]').each(function () {\nt.push(this.name+\"=\"+this.value);\n});\n\nlet unique = [...new Set(t)];\njQuery(\"#form-field-hcaptcha\").val(btoa(unique.join(\"|\")))\n\n\n\n},5000);\n\n\n<\/script>\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 elementor-animation-shrink\" 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\">Send<\/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<div class=\"elementor-element elementor-element-2ddb324 e-con-full blurry elementor-hidden-widescreen elementor-hidden-desktop elementor-hidden-laptop e-flex e-con e-child\" data-id=\"2ddb324\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-fe4c5fc elementor-widget elementor-widget-jet-headline\" data-id=\"fe4c5fc\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"jet-headline.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p class=\"jet-headline jet-headline--direction-horizontal\"><span class=\"jet-headline__part jet-headline__first\"><span class=\"jet-headline__label\">Would you like to go<\/span><\/span><span class=\"jet-headline__part jet-headline__second\"><span class=\"jet-headline__label\">&nbsp;one step further?<\/span><\/span><\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e9d2dc7 elementor-widget elementor-widget-spacer\" data-id=\"e9d2dc7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-07e6042 elementor-widget elementor-widget-text-editor\" data-id=\"07e6042\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p class=\"p1\">Then we offer you the opportunity to complete our patient questionnaire online.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-c13ae85 elementor-widget elementor-widget-spacer\" data-id=\"c13ae85\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7756916 elementor-widget__width-auto elementor-align-center elementor-widget elementor-widget-button\" data-id=\"7756916\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm elementor-animation-shrink\" href=\"#fragebogen\" aria-label=\"Zum Patientenfragebogen\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"alpstein alpstein-Pfeil-unten\"><\/i>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">To the patient questionnaire<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\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\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-1ceffe4d e-con-full e-flex e-con e-parent\" data-id=\"1ceffe4d\" data-element_type=\"container\" data-e-type=\"container\" id=\"fragebogen\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t<div class=\"elementor-element elementor-element-6b3a74d0 e-con-full e-flex e-con e-child\" data-id=\"6b3a74d0\" data-element_type=\"container\" data-e-type=\"container\" id=\"fragebogen\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-52ba47ab elementor-widget__width-inherit elementor-widget elementor-widget-jet-headline\" data-id=\"52ba47ab\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"jet-headline.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"jet-headline jet-headline--direction-horizontal\"><span class=\"jet-headline__part jet-headline__first\"><span class=\"jet-headline__label\">Patients<\/span><\/span><span class=\"jet-headline__part jet-headline__second\"><span class=\"jet-headline__label\">fragebogen<\/span><\/span><\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7e673fcf elementor-widget elementor-widget-spacer\" data-id=\"7e673fcf\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-78f5daf5 elementor-button-align-end elementor-widget-mobile__width-initial elementor-widget elementor-widget-form\" data-id=\"78f5daf5\" 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;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"Patient questionnaire\" aria-label=\"Patient questionnaire\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"7574\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"78f5daf5\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Alpstein Clinic\" \/>\n\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-step elementor-field-group elementor-column elementor-field-group-step1 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Contact data\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\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-salutation elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-salutation\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSalutation\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<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[salutation]\" id=\"form-field-salutation\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Mr. &lt;br&gt;Mrs.\">Mr. &lt;br&gt;Mrs.<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Divers\">Divers<\/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-firstname elementor-col-40 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-firstname\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst 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[firstname]\" id=\"form-field-firstname\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" 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-lastname elementor-col-40 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-lastname\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSurname*\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[lastname]\" id=\"form-field-lastname\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" 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-date elementor-field-group elementor-column elementor-field-group-dob elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dob\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[dob]\" id=\"form-field-dob\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field elementor-use-native\" 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-job elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-job\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tProfession\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[job]\" id=\"form-field-job\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-select elementor-field-group elementor-column elementor-field-group-civil_status elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-civil_status\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCivil status\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<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[civil_status]\" id=\"form-field-civil_status\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"--- Please select ---\">--- Please select ---<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Single\">Single<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Married\">Married<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Divorced\">Divorced<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Widowed\">Widowed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"In registered partnership\">In registered partnership<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"In dissolved partnership\">In dissolved partnership<\/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-street elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-street\" 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[street]\" id=\"form-field-street\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Strasse und Hausnummer\" 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-streetex elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-streetex\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress suffix\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[streetex]\" id=\"form-field-streetex\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"e.g. P.O. Box\">\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-zip elementor-col-30 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-zip\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPostal code*\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[zip]\" id=\"form-field-zip\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" 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-city elementor-col-40 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-city\" 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[city]\" id=\"form-field-city\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" 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-select elementor-field-group elementor-column elementor-field-group-country elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-country\" 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 remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[country]\" id=\"form-field-country\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"--- Please select ---\">--- Please select ---<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AF\">Afghanistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AL\">Albania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DZ\">Algeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AD\">Andorra<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AO\">Angola<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AG\">Antigua und Barbuda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AR\">Argentina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AM\">Armenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AU\">Australia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AT\">Austria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AZ\">Azerbaijan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BS\">Bahamas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BH\">Bahrain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BD\">Bangladesch<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BB\">Barbados<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BY\">Belarus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BE\">Belgium<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BZ\">Belize<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BJ\">Benin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BT\">Bhutan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BO\">Bolivia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BA\">Bosnia and Herzegovnia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BW\">Botswana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BR\">Brasil<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BN\">Brunei<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BG\">Bulgaria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BF\">Burkina Faso<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BI\">Burundi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KH\">Cambodia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CM\">Kamerun<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CA\">Canada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CV\">Cape Verde<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CF\">Central African Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TD\">Tschad<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CL\">Chile<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CN\">China<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CO\">Columbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KM\">Komoren<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CG\">Kongo (Brazzaville)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CD\">Kongo (Kinshasa)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CR\">Costa Rica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HR\">Croatia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CU\">Cuba<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CY\">Cyprus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CZ\">Czech Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DK\">Denmark<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DJ\">Dschibuti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DM\">Dominica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DO\">Dominican Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EC\">Ecuador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EG\">Egypt<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SV\">El Salvador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GQ\">Equatorial Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ER\">Eritrea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EE\">Estland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SZ\">Eswatini<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ET\">Ethiopia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FJ\">Fiji<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FI\">Finland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FR\">France<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GA\">Gabun<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GM\">Gambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GE\">Georgien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DE\">Germany<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GH\">Ghana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GR\">Greece<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GD\">Grenada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GT\">Guatemala<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GN\">Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GW\">Guinea-Bissau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GY\">Guyana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HT\">Haiti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HN\">Honduras<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HU\">Hungary<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IS\">Iceland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IN\">India<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ID\">Indonesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IR\">Iran<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IQ\">Iraq<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IE\">Ireland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IL\">Israel<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IT\">Italy<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JM\">Jamaika<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JP\">Japan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JO\">Jordanien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KZ\">Kazakhstan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KE\">Kenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KI\">Kiribati<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KW\">Kuwait<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KG\">Kirgisistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LA\">Laos<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LV\">Latvia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LB\">Libanon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LS\">Lesotho<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LR\">Liberia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LY\">Libyen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LI\">Liechtenstein<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LT\">Lithuania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LU\">Luxembourg<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MG\">Madagascar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MW\">Malawi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MY\">Malaysia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MV\">Maledives<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ML\">Mali<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MT\">Malta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MH\">Marshall Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MR\">Mauretanien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MU\">Mauritius<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MX\">Mexico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FM\">Mikronesien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MD\">Moldawien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MC\">Monaco<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MN\">Mongolia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ME\">Montenegro<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MA\">Morocco<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MZ\">Mozambique<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MM\">Myanmar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NA\">Namibia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NR\">Nauru<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NP\">Nepal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NL\">Netherlands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NZ\">New Zealand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NI\">Nicaragua<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NE\">Niger<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NG\">Nigeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KP\">North Korea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MK\">North Macedonia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NO\">Norway<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OM\">Oman<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PK\">Pakistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PW\">Palau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PA\">Panama<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PG\">Papua-Neuguinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PY\">Paraguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PE\">Peru<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PH\">Philippines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PL\">Poland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PT\">Portugal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"QA\">Qatar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RO\">Romania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RU\">Russia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RW\">Ruanda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KN\">St. Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LC\">St. Lucia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VC\">St. Vincent and the Grenadines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WS\">Samoa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SM\">San Marino<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ST\">S\u00e3o Tom\u00e9 and Pr\u00edncipe<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SA\">Saudi Arabia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SN\">Senegal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RS\">Serbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SC\">Seychellen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SL\">Sierra Leone<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SG\">Singapur<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SK\">Slovakia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SI\">Slovenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SB\">Salomonen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SO\">Somalia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZA\">South Africa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KR\">South Korea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SS\">South Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ES\">Spain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LK\">Sri Lanka<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SD\">Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SR\">Suriname<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SE\">Sweden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CH\">Switzerland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SY\">Syria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TW\">Taiwan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TJ\">Tadschikistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TZ\">Tansania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TH\">Thailand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TL\">Timor-Leste<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TG\">Togo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TO\">Tonga<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TT\">Trinidad and Tobago<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TN\">Tunesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TR\">Turkey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TM\">Turkmenistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TV\">Tuvalu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UG\">Uganda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UA\">Ukraine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AE\">United Arab Emirates<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GB\">United Kingdom<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"US\">USA<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UY\">Uruguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UZ\">Usbekistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VU\">Vanuatu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VA\">Vatican City<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VE\">Venezuela<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VN\">Vietnam<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"YE\">Yemen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZM\">Sambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZW\">Simbabwe<\/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-phone elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-phone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone\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[phone]\" id=\"form-field-phone\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-mobile elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-mobile\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMobile\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[mobile]\" id=\"form-field-mobile\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-phone2 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-phone2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCompany phone \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[phone2]\" id=\"form-field-phone2\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-email elementor-field-group elementor-column elementor-field-group-email elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tE-mail address*\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[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" 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\">\n\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[email2]\" id=\"form-field-email2\" class=\"elementor-field elementor-size-sm \" style=\"display:none !important;\">\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-step2 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Emergency contact\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_82121a3 elementor-col-100\">\n\t\t\t\t\t<h3><strong>Your emergency contact<\/strong><\/h3>\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-hx_Notfallkontakt elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Notfallkontakt\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName of emergency contact\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[hx_Notfallkontakt]\" id=\"form-field-hx_Notfallkontakt\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-hx_Phone_Notfall elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Phone_Notfall\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone of emergency contact\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[hx_Phone_Notfall]\" id=\"form-field-hx_Phone_Notfall\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-hx_Mobile_Notfall elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Mobile_Notfall\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMobile nr. of emergency contact\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[hx_Mobile_Notfall]\" id=\"form-field-hx_Mobile_Notfall\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-hx_Adresse_Notfall elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Adresse_Notfall\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress of emergency contact\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[hx_Adresse_Notfall]\" id=\"form-field-hx_Adresse_Notfall\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Street, house number, ZIP code, and city\">\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-select elementor-field-group elementor-column elementor-field-group-hx_Land_Notfall elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Land_Notfall\" 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 remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[hx_Land_Notfall]\" id=\"form-field-hx_Land_Notfall\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"--- Please select ---\">--- Please select ---<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AF\">Afghanistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AL\">Albania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DZ\">Algeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AD\">Andorra<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AO\">Angola<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AG\">Antigua und Barbuda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AR\">Argentina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AM\">Armenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AU\">Australia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AT\">Austria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AZ\">Azerbaijan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BS\">Bahamas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BH\">Bahrain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BD\">Bangladesch<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BB\">Barbados<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BY\">Belarus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BE\">Belgium<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BZ\">Belize<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BJ\">Benin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BT\">Bhutan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BO\">Bolivia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BA\">Bosnia and Herzegovnia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BW\">Botswana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BR\">Brasil<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BN\">Brunei<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BG\">Bulgaria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BF\">Burkina Faso<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BI\">Burundi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KH\">Cambodia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CM\">Kamerun<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CA\">Canada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CV\">Cape Verde<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CF\">Central African Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TD\">Tschad<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CL\">Chile<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CN\">China<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CO\">Columbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KM\">Komoren<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CG\">Kongo (Brazzaville)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CD\">Kongo (Kinshasa)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CR\">Costa Rica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HR\">Croatia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CU\">Cuba<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CY\">Cyprus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CZ\">Czech Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DK\">Denmark<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DJ\">Dschibuti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DM\">Dominica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DO\">Dominican Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EC\">Ecuador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EG\">Egypt<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SV\">El Salvador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GQ\">Equatorial Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ER\">Eritrea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EE\">Estland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SZ\">Eswatini<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ET\">Ethiopia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FJ\">Fiji<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FI\">Finland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FR\">France<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GA\">Gabun<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GM\">Gambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GE\">Georgien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DE\">Germany<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GH\">Ghana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GR\">Greece<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GD\">Grenada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GT\">Guatemala<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GN\">Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GW\">Guinea-Bissau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GY\">Guyana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HT\">Haiti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HN\">Honduras<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HU\">Hungary<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IS\">Iceland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IN\">India<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ID\">Indonesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IR\">Iran<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IQ\">Iraq<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IE\">Ireland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IL\">Israel<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IT\">Italy<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JM\">Jamaika<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JP\">Japan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JO\">Jordanien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KZ\">Kazakhstan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KE\">Kenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KI\">Kiribati<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KW\">Kuwait<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KG\">Kirgisistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LA\">Laos<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LV\">Latvia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LB\">Libanon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LS\">Lesotho<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LR\">Liberia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LY\">Libyen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LI\">Liechtenstein<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LT\">Lithuania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LU\">Luxembourg<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MG\">Madagascar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MW\">Malawi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MY\">Malaysia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MV\">Maledives<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ML\">Mali<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MT\">Malta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MH\">Marshall Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MR\">Mauretanien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MU\">Mauritius<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MX\">Mexico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FM\">Mikronesien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MD\">Moldawien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MC\">Monaco<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MN\">Mongolia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ME\">Montenegro<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MA\">Morocco<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MZ\">Mozambique<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MM\">Myanmar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NA\">Namibia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NR\">Nauru<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NP\">Nepal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NL\">Netherlands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NZ\">New Zealand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NI\">Nicaragua<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NE\">Niger<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NG\">Nigeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KP\">North Korea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MK\">North Macedonia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NO\">Norway<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OM\">Oman<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PK\">Pakistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PW\">Palau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PA\">Panama<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PG\">Papua-Neuguinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PY\">Paraguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PE\">Peru<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PH\">Philippines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PL\">Poland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PT\">Portugal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"QA\">Qatar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RO\">Romania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RU\">Russia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RW\">Ruanda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KN\">St. Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LC\">St. Lucia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VC\">St. Vincent and the Grenadines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WS\">Samoa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SM\">San Marino<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ST\">S\u00e3o Tom\u00e9 and Pr\u00edncipe<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SA\">Saudi Arabia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SN\">Senegal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RS\">Serbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SC\">Seychellen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SL\">Sierra Leone<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SG\">Singapur<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SK\">Slovakia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SI\">Slovenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SB\">Salomonen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SO\">Somalia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZA\">South Africa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KR\">South Korea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SS\">South Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ES\">Spain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LK\">Sri Lanka<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SD\">Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SR\">Suriname<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SE\">Sweden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CH\">Switzerland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SY\">Syria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TW\">Taiwan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TJ\">Tadschikistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TZ\">Tansania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TH\">Thailand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TL\">Timor-Leste<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TG\">Togo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TO\">Tonga<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TT\">Trinidad and Tobago<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TN\">Tunesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TR\">Turkey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TM\">Turkmenistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TV\">Tuvalu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UG\">Uganda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UA\">Ukraine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AE\">United Arab Emirates<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GB\">United Kingdom<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"US\">USA<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UY\">Uruguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UZ\">Usbekistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VU\">Vanuatu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VA\">Vatican City<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VE\">Venezuela<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VN\">Vietnam<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"YE\">Yemen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZM\">Sambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZW\">Simbabwe<\/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-step elementor-field-group elementor-column elementor-field-group-step3 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Insurances\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_c43a8b2 elementor-col-100\">\n\t\t\t\t\t<h3><strong>Basic health insurance<\/strong><\/h3>\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-kvg elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-kvg\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName\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[kvg]\" id=\"form-field-kvg\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-police_nr elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-police_nr\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInsurance no. \/ AHV number \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[police_nr]\" id=\"form-field-police_nr\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-hx_Adresse_Grundversicherung elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Adresse_Grundversicherung\" 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[hx_Adresse_Grundversicherung]\" id=\"form-field-hx_Adresse_Grundversicherung\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Street, house number, ZIP code, and city\">\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-select elementor-field-group elementor-column elementor-field-group-hx_Land_Grundversicherung elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Land_Grundversicherung\" 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 remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[hx_Land_Grundversicherung]\" id=\"form-field-hx_Land_Grundversicherung\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"--- Please select ---\">--- Please select ---<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AF\">Afghanistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AL\">Albania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DZ\">Algeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AD\">Andorra<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AO\">Angola<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AG\">Antigua und Barbuda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AR\">Argentina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AM\">Armenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AU\">Australia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AT\">Austria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AZ\">Azerbaijan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BS\">Bahamas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BH\">Bahrain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BD\">Bangladesch<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BB\">Barbados<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BY\">Belarus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BE\">Belgium<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BZ\">Belize<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BJ\">Benin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BT\">Bhutan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BO\">Bolivia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BA\">Bosnia and Herzegovnia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BW\">Botswana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BR\">Brasil<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BN\">Brunei<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BG\">Bulgaria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BF\">Burkina Faso<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BI\">Burundi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KH\">Cambodia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CM\">Kamerun<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CA\">Canada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CV\">Cape Verde<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CF\">Central African Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TD\">Tschad<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CL\">Chile<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CN\">China<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CO\">Columbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KM\">Komoren<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CG\">Kongo (Brazzaville)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CD\">Kongo (Kinshasa)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CR\">Costa Rica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HR\">Croatia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CU\">Cuba<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CY\">Cyprus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CZ\">Czech Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DK\">Denmark<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DJ\">Dschibuti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DM\">Dominica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DO\">Dominican Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EC\">Ecuador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EG\">Egypt<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SV\">El Salvador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GQ\">Equatorial Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ER\">Eritrea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EE\">Estland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SZ\">Eswatini<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ET\">Ethiopia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FJ\">Fiji<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FI\">Finland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FR\">France<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GA\">Gabun<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GM\">Gambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GE\">Georgien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DE\">Germany<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GH\">Ghana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GR\">Greece<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GD\">Grenada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GT\">Guatemala<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GN\">Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GW\">Guinea-Bissau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GY\">Guyana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HT\">Haiti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HN\">Honduras<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HU\">Hungary<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IS\">Iceland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IN\">India<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ID\">Indonesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IR\">Iran<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IQ\">Iraq<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IE\">Ireland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IL\">Israel<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IT\">Italy<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JM\">Jamaika<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JP\">Japan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JO\">Jordanien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KZ\">Kazakhstan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KE\">Kenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KI\">Kiribati<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KW\">Kuwait<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KG\">Kirgisistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LA\">Laos<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LV\">Latvia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LB\">Libanon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LS\">Lesotho<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LR\">Liberia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LY\">Libyen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LI\">Liechtenstein<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LT\">Lithuania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LU\">Luxembourg<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MG\">Madagascar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MW\">Malawi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MY\">Malaysia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MV\">Maledives<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ML\">Mali<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MT\">Malta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MH\">Marshall Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MR\">Mauretanien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MU\">Mauritius<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MX\">Mexico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FM\">Mikronesien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MD\">Moldawien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MC\">Monaco<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MN\">Mongolia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ME\">Montenegro<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MA\">Morocco<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MZ\">Mozambique<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MM\">Myanmar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NA\">Namibia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NR\">Nauru<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NP\">Nepal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NL\">Netherlands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NZ\">New Zealand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NI\">Nicaragua<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NE\">Niger<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NG\">Nigeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KP\">North Korea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MK\">North Macedonia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NO\">Norway<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OM\">Oman<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PK\">Pakistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PW\">Palau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PA\">Panama<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PG\">Papua-Neuguinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PY\">Paraguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PE\">Peru<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PH\">Philippines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PL\">Poland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PT\">Portugal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"QA\">Qatar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RO\">Romania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RU\">Russia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RW\">Ruanda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KN\">St. Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LC\">St. Lucia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VC\">St. Vincent and the Grenadines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WS\">Samoa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SM\">San Marino<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ST\">S\u00e3o Tom\u00e9 and Pr\u00edncipe<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SA\">Saudi Arabia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SN\">Senegal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RS\">Serbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SC\">Seychellen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SL\">Sierra Leone<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SG\">Singapur<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SK\">Slovakia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SI\">Slovenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SB\">Salomonen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SO\">Somalia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZA\">South Africa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KR\">South Korea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SS\">South Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ES\">Spain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LK\">Sri Lanka<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SD\">Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SR\">Suriname<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SE\">Sweden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CH\">Switzerland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SY\">Syria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TW\">Taiwan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TJ\">Tadschikistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TZ\">Tansania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TH\">Thailand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TL\">Timor-Leste<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TG\">Togo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TO\">Tonga<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TT\">Trinidad and Tobago<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TN\">Tunesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TR\">Turkey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TM\">Turkmenistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TV\">Tuvalu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UG\">Uganda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UA\">Ukraine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AE\">United Arab Emirates<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GB\">United Kingdom<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"US\">USA<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UY\">Uruguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UZ\">Usbekistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VU\">Vanuatu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VA\">Vatican City<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VE\">Venezuela<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VN\">Vietnam<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"YE\">Yemen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZM\">Sambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZW\">Simbabwe<\/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-html elementor-field-group elementor-column elementor-field-group-field_4578b5e elementor-col-100\">\n\t\t\t\t\t<h3><strong> Health Insurance: Supplemental Coverage <\/strong><\/h3>\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-hx_Name_Zusatzversicherung elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Name_Zusatzversicherung\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName\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[hx_Name_Zusatzversicherung]\" id=\"form-field-hx_Name_Zusatzversicherung\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-hx_Versicherungsnummer_Zusatzversicherung elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Versicherungsnummer_Zusatzversicherung\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInsurance no. \/ AHV number \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[hx_Versicherungsnummer_Zusatzversicherung]\" id=\"form-field-hx_Versicherungsnummer_Zusatzversicherung\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-hx_Adresse_Zusatzversicherung elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Adresse_Zusatzversicherung\" 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[hx_Adresse_Zusatzversicherung]\" id=\"form-field-hx_Adresse_Zusatzversicherung\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Strasse, Hausnummer, PLZ und Ort\">\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-select elementor-field-group elementor-column elementor-field-group-hx_Land_Zusatzversicherung elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Land_Zusatzversicherung\" 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 remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[hx_Land_Zusatzversicherung]\" id=\"form-field-hx_Land_Zusatzversicherung\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"--- Please select ---\">--- Please select ---<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AF\">Afghanistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AL\">Albania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DZ\">Algeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AD\">Andorra<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AO\">Angola<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AG\">Antigua und Barbuda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AR\">Argentina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AM\">Armenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AU\">Australia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AT\">Austria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AZ\">Azerbaijan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BS\">Bahamas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BH\">Bahrain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BD\">Bangladesch<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BB\">Barbados<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BY\">Belarus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BE\">Belgium<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BZ\">Belize<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BJ\">Benin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BT\">Bhutan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BO\">Bolivia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BA\">Bosnia and Herzegovnia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BW\">Botswana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BR\">Brasil<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BN\">Brunei<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BG\">Bulgaria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BF\">Burkina Faso<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BI\">Burundi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KH\">Cambodia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CM\">Kamerun<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CA\">Canada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CV\">Cape Verde<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CF\">Central African Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TD\">Tschad<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CL\">Chile<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CN\">China<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CO\">Columbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KM\">Komoren<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CG\">Kongo (Brazzaville)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CD\">Kongo (Kinshasa)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CR\">Costa Rica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HR\">Croatia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CU\">Cuba<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CY\">Cyprus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CZ\">Czech Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DK\">Denmark<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DJ\">Dschibuti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DM\">Dominica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DO\">Dominican Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EC\">Ecuador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EG\">Egypt<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SV\">El Salvador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GQ\">Equatorial Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ER\">Eritrea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EE\">Estland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SZ\">Eswatini<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ET\">Ethiopia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FJ\">Fiji<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FI\">Finland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FR\">France<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GA\">Gabun<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GM\">Gambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GE\">Georgien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DE\">Germany<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GH\">Ghana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GR\">Greece<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GD\">Grenada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GT\">Guatemala<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GN\">Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GW\">Guinea-Bissau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GY\">Guyana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HT\">Haiti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HN\">Honduras<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HU\">Hungary<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IS\">Iceland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IN\">India<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ID\">Indonesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IR\">Iran<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IQ\">Iraq<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IE\">Ireland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IL\">Israel<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IT\">Italy<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JM\">Jamaika<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JP\">Japan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JO\">Jordanien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KZ\">Kazakhstan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KE\">Kenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KI\">Kiribati<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KW\">Kuwait<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KG\">Kirgisistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LA\">Laos<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LV\">Latvia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LB\">Libanon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LS\">Lesotho<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LR\">Liberia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LY\">Libyen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LI\">Liechtenstein<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LT\">Lithuania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LU\">Luxembourg<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MG\">Madagascar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MW\">Malawi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MY\">Malaysia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MV\">Maledives<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ML\">Mali<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MT\">Malta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MH\">Marshall Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MR\">Mauretanien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MU\">Mauritius<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MX\">Mexico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FM\">Mikronesien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MD\">Moldawien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MC\">Monaco<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MN\">Mongolia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ME\">Montenegro<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MA\">Morocco<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MZ\">Mozambique<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MM\">Myanmar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NA\">Namibia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NR\">Nauru<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NP\">Nepal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NL\">Netherlands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NZ\">New Zealand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NI\">Nicaragua<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NE\">Niger<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NG\">Nigeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KP\">North Korea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MK\">North Macedonia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NO\">Norway<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OM\">Oman<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PK\">Pakistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PW\">Palau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PA\">Panama<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PG\">Papua-Neuguinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PY\">Paraguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PE\">Peru<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PH\">Philippines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PL\">Poland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PT\">Portugal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"QA\">Qatar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RO\">Romania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RU\">Russia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RW\">Ruanda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KN\">St. Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LC\">St. Lucia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VC\">St. Vincent and the Grenadines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WS\">Samoa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SM\">San Marino<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ST\">S\u00e3o Tom\u00e9 and Pr\u00edncipe<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SA\">Saudi Arabia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SN\">Senegal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RS\">Serbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SC\">Seychellen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SL\">Sierra Leone<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SG\">Singapur<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SK\">Slovakia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SI\">Slovenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SB\">Salomonen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SO\">Somalia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZA\">South Africa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KR\">South Korea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SS\">South Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ES\">Spain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LK\">Sri Lanka<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SD\">Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SR\">Suriname<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SE\">Sweden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CH\">Switzerland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SY\">Syria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TW\">Taiwan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TJ\">Tadschikistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TZ\">Tansania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TH\">Thailand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TL\">Timor-Leste<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TG\">Togo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TO\">Tonga<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TT\">Trinidad and Tobago<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TN\">Tunesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TR\">Turkey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TM\">Turkmenistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TV\">Tuvalu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UG\">Uganda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UA\">Ukraine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AE\">United Arab Emirates<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GB\">United Kingdom<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"US\">USA<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UY\">Uruguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UZ\">Usbekistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VU\">Vanuatu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VA\">Vatican City<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VE\">Venezuela<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VN\">Vietnam<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"YE\">Yemen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZM\">Sambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZW\">Simbabwe<\/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-html elementor-field-group elementor-column elementor-field-group-field_e9108e9 elementor-col-100\">\n\t\t\t\t\t<h3><strong> Health Insurance: Supplemental Coverage<\/strong><\/h3>\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-hx_Name_Zahnzusatzversicherung elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Name_Zahnzusatzversicherung\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName\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[hx_Name_Zahnzusatzversicherung]\" id=\"form-field-hx_Name_Zahnzusatzversicherung\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-hx_Versicherungsnummer_Zahnzusatzversicherung elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Versicherungsnummer_Zahnzusatzversicherung\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInsurance no. \/ AHV number \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[hx_Versicherungsnummer_Zahnzusatzversicherung]\" id=\"form-field-hx_Versicherungsnummer_Zahnzusatzversicherung\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-hx_Adresse_Zahnzusatzversicherung elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Adresse_Zahnzusatzversicherung\" 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[hx_Adresse_Zahnzusatzversicherung]\" id=\"form-field-hx_Adresse_Zahnzusatzversicherung\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Street, house number, ZIP code, and city\">\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-select elementor-field-group elementor-column elementor-field-group-hx_Land_Zahnzusatzversicherung elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Land_Zahnzusatzversicherung\" 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 remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[hx_Land_Zahnzusatzversicherung]\" id=\"form-field-hx_Land_Zahnzusatzversicherung\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"--- Please select ---\">--- Please select ---<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AF\">Afghanistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AL\">Albania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DZ\">Algeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AD\">Andorra<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AO\">Angola<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AG\">Antigua und Barbuda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AR\">Argentina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AM\">Armenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AU\">Australia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AT\">Austria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AZ\">Azerbaijan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BS\">Bahamas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BH\">Bahrain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BD\">Bangladesch<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BB\">Barbados<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BY\">Belarus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BE\">Belgium<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BZ\">Belize<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BJ\">Benin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BT\">Bhutan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BO\">Bolivia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BA\">Bosnia and Herzegovnia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BW\">Botswana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BR\">Brasil<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BN\">Brunei<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BG\">Bulgaria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BF\">Burkina Faso<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BI\">Burundi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KH\">Cambodia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CM\">Kamerun<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CA\">Canada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CV\">Cape Verde<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CF\">Central African Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TD\">Tschad<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CL\">Chile<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CN\">China<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CO\">Columbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KM\">Komoren<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CG\">Kongo (Brazzaville)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CD\">Kongo (Kinshasa)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CR\">Costa Rica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HR\">Croatia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CU\">Cuba<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CY\">Cyprus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CZ\">Czech Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DK\">Denmark<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DJ\">Dschibuti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DM\">Dominica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DO\">Dominican Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EC\">Ecuador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EG\">Egypt<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SV\">El Salvador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GQ\">Equatorial Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ER\">Eritrea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EE\">Estland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SZ\">Eswatini<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ET\">Ethiopia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FJ\">Fiji<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FI\">Finland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FR\">France<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GA\">Gabun<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GM\">Gambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GE\">Georgien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DE\">Germany<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GH\">Ghana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GR\">Greece<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GD\">Grenada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GT\">Guatemala<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GN\">Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GW\">Guinea-Bissau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GY\">Guyana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HT\">Haiti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HN\">Honduras<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HU\">Hungary<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IS\">Iceland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IN\">India<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ID\">Indonesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IR\">Iran<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IQ\">Iraq<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IE\">Ireland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IL\">Israel<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IT\">Italy<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JM\">Jamaika<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JP\">Japan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JO\">Jordanien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KZ\">Kazakhstan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KE\">Kenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KI\">Kiribati<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KW\">Kuwait<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KG\">Kirgisistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LA\">Laos<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LV\">Latvia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LB\">Libanon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LS\">Lesotho<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LR\">Liberia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LY\">Libyen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LI\">Liechtenstein<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LT\">Lithuania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LU\">Luxembourg<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MG\">Madagascar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MW\">Malawi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MY\">Malaysia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MV\">Maledives<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ML\">Mali<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MT\">Malta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MH\">Marshall Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MR\">Mauretanien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MU\">Mauritius<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MX\">Mexico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FM\">Mikronesien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MD\">Moldawien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MC\">Monaco<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MN\">Mongolia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ME\">Montenegro<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MA\">Morocco<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MZ\">Mozambique<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MM\">Myanmar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NA\">Namibia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NR\">Nauru<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NP\">Nepal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NL\">Netherlands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NZ\">New Zealand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NI\">Nicaragua<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NE\">Niger<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NG\">Nigeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KP\">North Korea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MK\">North Macedonia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NO\">Norway<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OM\">Oman<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PK\">Pakistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PW\">Palau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PA\">Panama<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PG\">Papua-Neuguinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PY\">Paraguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PE\">Peru<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PH\">Philippines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PL\">Poland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PT\">Portugal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"QA\">Qatar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RO\">Romania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RU\">Russia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RW\">Ruanda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KN\">St. Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LC\">St. Lucia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VC\">St. Vincent and the Grenadines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WS\">Samoa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SM\">San Marino<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ST\">S\u00e3o Tom\u00e9 and Pr\u00edncipe<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SA\">Saudi Arabia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SN\">Senegal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RS\">Serbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SC\">Seychellen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SL\">Sierra Leone<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SG\">Singapur<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SK\">Slovakia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SI\">Slovenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SB\">Salomonen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SO\">Somalia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZA\">South Africa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KR\">South Korea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SS\">South Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ES\">Spain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LK\">Sri Lanka<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SD\">Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SR\">Suriname<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SE\">Sweden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CH\">Switzerland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SY\">Syria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TW\">Taiwan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TJ\">Tadschikistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TZ\">Tansania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TH\">Thailand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TL\">Timor-Leste<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TG\">Togo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TO\">Tonga<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TT\">Trinidad and Tobago<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TN\">Tunesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TR\">Turkey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TM\">Turkmenistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TV\">Tuvalu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UG\">Uganda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UA\">Ukraine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AE\">United Arab Emirates<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GB\">United Kingdom<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"US\">USA<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UY\">Uruguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UZ\">Usbekistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VU\">Vanuatu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VA\">Vatican City<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VE\">Venezuela<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VN\">Vietnam<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"YE\">Yemen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZM\">Sambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZW\">Simbabwe<\/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-html elementor-field-group elementor-column elementor-field-group-field_2e49e5e elementor-col-100\">\n\t\t\t\t\t<h3>Billing<\/h3>\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-hx_Leistungsabrechnung elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Leistungsabrechnung\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBilling\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<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[hx_Leistungsabrechnung]\" id=\"form-field-hx_Leistungsabrechnung\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"--- Please select ---\">--- Please select ---<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Send invoice to you (TG)\">Send invoice to you (TG)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Send invoice to your health insurance provider (TP)\">Send invoice to your health insurance provider (TP)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Send invoice to another entity (UV, IV, MV o. a.)\">Send invoice to another entity (UV, IV, MV o. a.)<\/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-step elementor-field-group elementor-column elementor-field-group-step4 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Family doctor\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_9bfdf31 elementor-col-100\">\n\t\t\t\t\t<h3><strong>Family doctor<\/strong><\/h3>\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-hx_Vorname_Hausarzt elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Vorname_Hausarzt\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst 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[hx_Vorname_Hausarzt]\" id=\"form-field-hx_Vorname_Hausarzt\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-hx_Nachname_Hausarzt elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Nachname_Hausarzt\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLast 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[hx_Nachname_Hausarzt]\" id=\"form-field-hx_Nachname_Hausarzt\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-hx_Adresse_Hausarzt elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Adresse_Hausarzt\" 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[hx_Adresse_Hausarzt]\" id=\"form-field-hx_Adresse_Hausarzt\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Strasse, Hausnummer, PLZ und Ort\">\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-select elementor-field-group elementor-column elementor-field-group-hx_Land_Hausarzt elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Land_Hausarzt\" 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 remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[hx_Land_Hausarzt]\" id=\"form-field-hx_Land_Hausarzt\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"--- Please select ---\">--- Please select ---<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AF\">Afghanistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AL\">Albania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DZ\">Algeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AD\">Andorra<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AO\">Angola<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AG\">Antigua und Barbuda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AR\">Argentina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AM\">Armenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AU\">Australia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AT\">Austria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AZ\">Azerbaijan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BS\">Bahamas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BH\">Bahrain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BD\">Bangladesch<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BB\">Barbados<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BY\">Belarus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BE\">Belgium<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BZ\">Belize<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BJ\">Benin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BT\">Bhutan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BO\">Bolivia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BA\">Bosnia and Herzegovnia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BW\">Botswana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BR\">Brasil<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BN\">Brunei<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BG\">Bulgaria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BF\">Burkina Faso<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"BI\">Burundi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KH\">Cambodia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CM\">Kamerun<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CA\">Canada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CV\">Cape Verde<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CF\">Central African Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TD\">Tschad<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CL\">Chile<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CN\">China<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CO\">Columbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KM\">Komoren<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CG\">Kongo (Brazzaville)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CD\">Kongo (Kinshasa)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CR\">Costa Rica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HR\">Croatia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CU\">Cuba<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CY\">Cyprus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CZ\">Czech Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DK\">Denmark<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DJ\">Dschibuti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DM\">Dominica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DO\">Dominican Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EC\">Ecuador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EG\">Egypt<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SV\">El Salvador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GQ\">Equatorial Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ER\">Eritrea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EE\">Estland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SZ\">Eswatini<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ET\">Ethiopia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FJ\">Fiji<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FI\">Finland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FR\">France<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GA\">Gabun<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GM\">Gambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GE\">Georgien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DE\">Germany<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GH\">Ghana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GR\">Greece<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GD\">Grenada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GT\">Guatemala<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GN\">Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GW\">Guinea-Bissau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GY\">Guyana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HT\">Haiti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HN\">Honduras<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HU\">Hungary<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IS\">Iceland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IN\">India<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ID\">Indonesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IR\">Iran<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IQ\">Iraq<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IE\">Ireland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IL\">Israel<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IT\">Italy<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JM\">Jamaika<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JP\">Japan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"JO\">Jordanien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KZ\">Kazakhstan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KE\">Kenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KI\">Kiribati<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KW\">Kuwait<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KG\">Kirgisistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LA\">Laos<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LV\">Latvia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LB\">Libanon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LS\">Lesotho<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LR\">Liberia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LY\">Libyen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LI\">Liechtenstein<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LT\">Lithuania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LU\">Luxembourg<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MG\">Madagascar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MW\">Malawi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MY\">Malaysia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MV\">Maledives<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ML\">Mali<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MT\">Malta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MH\">Marshall Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MR\">Mauretanien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MU\">Mauritius<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MX\">Mexico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FM\">Mikronesien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MD\">Moldawien<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MC\">Monaco<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MN\">Mongolia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ME\">Montenegro<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MA\">Morocco<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MZ\">Mozambique<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MM\">Myanmar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NA\">Namibia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NR\">Nauru<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NP\">Nepal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NL\">Netherlands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NZ\">New Zealand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NI\">Nicaragua<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NE\">Niger<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NG\">Nigeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KP\">North Korea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MK\">North Macedonia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NO\">Norway<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OM\">Oman<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PK\">Pakistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PW\">Palau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PA\">Panama<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PG\">Papua-Neuguinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PY\">Paraguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PE\">Peru<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PH\">Philippines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PL\">Poland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PT\">Portugal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"QA\">Qatar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RO\">Romania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RU\">Russia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RW\">Ruanda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KN\">St. Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LC\">St. Lucia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VC\">St. Vincent and the Grenadines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WS\">Samoa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SM\">San Marino<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ST\">S\u00e3o Tom\u00e9 and Pr\u00edncipe<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SA\">Saudi Arabia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SN\">Senegal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RS\">Serbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SC\">Seychellen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SL\">Sierra Leone<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SG\">Singapur<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SK\">Slovakia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SI\">Slovenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SB\">Salomonen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SO\">Somalia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZA\">South Africa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KR\">South Korea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SS\">South Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ES\">Spain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LK\">Sri Lanka<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SD\">Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SR\">Suriname<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SE\">Sweden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CH\">Switzerland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SY\">Syria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TW\">Taiwan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TJ\">Tadschikistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TZ\">Tansania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TH\">Thailand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TL\">Timor-Leste<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TG\">Togo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TO\">Tonga<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TT\">Trinidad and Tobago<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TN\">Tunesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TR\">Turkey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TM\">Turkmenistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TV\">Tuvalu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UG\">Uganda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UA\">Ukraine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AE\">United Arab Emirates<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GB\">United Kingdom<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"US\">USA<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UY\">Uruguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UZ\">Usbekistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VU\">Vanuatu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VA\">Vatican City<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VE\">Venezuela<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VN\">Vietnam<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"YE\">Yemen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZM\">Sambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZW\">Simbabwe<\/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-step elementor-field-group elementor-column elementor-field-group-step5 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Medical\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_bd40c0b elementor-col-100\">\n\t\t\t\t\t<h3><strong> Human Health: Diseases \/ Ailments<\/strong><\/h3>\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-hx_Grund_Arztbesuch elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Grund_Arztbesuch\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhat is the reason for your visit to the doctor?\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[hx_Grund_Arztbesuch]\" id=\"form-field-hx_Grund_Arztbesuch\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-hx_Hauptbeschwerden elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Hauptbeschwerden\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhat are your main symptoms?\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[hx_Hauptbeschwerden]\" id=\"form-field-hx_Hauptbeschwerden\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-hx_Allergien elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Allergien\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you suffer from allergies?\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[hx_Allergien]\" id=\"form-field-hx_Allergien\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"If so, which ones?\">\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-hx_Operationen elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Operationen\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you had any surgeries?\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[hx_Operationen]\" id=\"form-field-hx_Operationen\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"If so, which ones?\">\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-textarea elementor-field-group elementor-column elementor-field-group-hx_Familienanamnese elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Familienanamnese\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you have any information about your family medical history?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[hx_Familienanamnese]\" id=\"form-field-hx_Familienanamnese\" rows=\"4\" placeholder=\"If so, which ones?\"><\/textarea>\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-hx_Kinder elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Kinder\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you have children?\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[hx_Kinder]\" id=\"form-field-hx_Kinder\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"If so, please specify how many, their gender, and their age group.\">\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-html elementor-field-group elementor-column elementor-field-group-field_df13005 elementor-col-100\">\n\t\t\t\t\t<p>&nbsp;<\/p>\n<h3><strong> Dental Health: Diseases \/ Conditions <\/strong><\/h3>\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-hx_Grund_Zahnarztbesuch elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Grund_Zahnarztbesuch\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhat is the reason for your visit to the dentist?\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[hx_Grund_Zahnarztbesuch]\" id=\"form-field-hx_Grund_Zahnarztbesuch\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-hx_Hauptbeschwerden_Dental elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Hauptbeschwerden_Dental\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhat are your main symptoms?\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[hx_Hauptbeschwerden_Dental]\" id=\"form-field-hx_Hauptbeschwerden_Dental\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\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-radio elementor-field-group elementor-column elementor-field-group-hx_Roentgenbilder elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Roentgenbilder\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you have any dental X-rays?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-hx_Roentgenbilder-0\" name=\"form_fields[hx_Roentgenbilder]\"> <label for=\"form-field-hx_Roentgenbilder-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-hx_Roentgenbilder-1\" name=\"form_fields[hx_Roentgenbilder]\"> <label for=\"form-field-hx_Roentgenbilder-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-step6 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Other\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\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-bloodtype elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-bloodtype\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBlood type\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<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[bloodtype]\" id=\"form-field-bloodtype\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"--- Please select ---\">--- Please select ---<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"A\">A<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"B \">B <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AB\">AB<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"O\">O<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"I don&#039;t know\">I don&#039;t know<\/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-html elementor-field-group elementor-column elementor-field-group-field_e7524f8 elementor-col-100\">\n\t\t\t\t\t<h3><strong> Medication \/ Treatments <\/strong><\/h3>\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-hx_Medikamente elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Medikamente\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you take medication regularly?\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[hx_Medikamente]\" id=\"form-field-hx_Medikamente\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"If so, which ones?\">\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-html elementor-field-group elementor-column elementor-field-group-field_3de43f0 elementor-col-100\">\n\t\t\t\t\t<h3><strong> Lifestyle <\/strong><\/h3>\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-hx_Ernaehrungsweise elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Ernaehrungsweise\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhat is your diet like?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[hx_Ernaehrungsweise]\" id=\"form-field-hx_Ernaehrungsweise\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-step7 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"General Information\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_e92b3a7 elementor-col-100\">\n\t\t\t\t\t<h3><strong> General Information <\/strong><\/h3>\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-hx_Empfehlung elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Empfehlung\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWere you referred by someone?\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[hx_Empfehlung]\" id=\"form-field-hx_Empfehlung\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"If so, by whom? Please provide the person&#039;s name, address, ZIP code, city, and country. \">\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-select elementor-field-group elementor-column elementor-field-group-hx_Aufmerksam_geworden elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Aufmerksam_geworden\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow did you hear about us?\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<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[hx_Aufmerksam_geworden]\" id=\"form-field-hx_Aufmerksam_geworden\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"--- Please select ---\">--- Please select ---<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Internet\">Internet<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Social Media\">Social Media<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Media reports\">Media reports<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Advertisement\">Advertisement<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/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-radio elementor-field-group elementor-column elementor-field-group-newsletter elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-newsletter\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWould you like to receive our newsletter?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"1\" id=\"form-field-newsletter-0\" name=\"form_fields[newsletter]\"> <label for=\"form-field-newsletter-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"0\" id=\"form-field-newsletter-1\" name=\"form_fields[newsletter]\"> <label for=\"form-field-newsletter-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-hx_Recall elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Recall\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you agree to the practice's appointment reminder system (for dental hygiene appointments)?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-hx_Recall-0\" name=\"form_fields[hx_Recall]\"> <label for=\"form-field-hx_Recall-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-hx_Recall-1\" name=\"form_fields[hx_Recall]\"> <label for=\"form-field-hx_Recall-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_74f6c78 elementor-col-100\">\n\t\t\t\t\tBy submitting this form, you confirm that the information you have provided is accurate.\n\nIf there are any changes to your health condition or insurance status during the course of treatment, please notify us as soon as possible.<br><br>If you fail to keep an appointment and cancel with less than 24 hours\u2019 notice, you will be charged a cancellation fee equal to the cost of the scheduled appointment.\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-bedingungen elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[bedingungen]\" id=\"form-field-bedingungen\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-bedingungen\">I accept the terms and conditions listed above.<\/label>\t\t\t<\/span>\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-acceptance elementor-field-group elementor-column elementor-field-group-agb elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[agb]\" id=\"form-field-agb\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-agb\">I hereby confirm that I have read the Terms and Conditions and agree to be bound by them.<\/label>\t\t\t<\/span>\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-acceptance elementor-field-group elementor-column elementor-field-group-datenschutz elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[datenschutz]\" id=\"form-field-datenschutz\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-datenschutz\">I have read the Privacy Policy and agree that my information and data may be collected and stored electronically for the purpose of responding to my inquiry.<br><br><strong>Note:<\/strong> You may revoke your consent at any time by sending an email to <a href=\"mailto:info@alpstein-clinic.ch\">info@alpstein-clinic.ch<\/a>.<\/label>\t\t\t<\/span>\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-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 elementor-animation-shrink\" 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\">Send<\/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\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Contact Do you have&nbsp;any questions? Call us on +41 71 791 81 00 and we will be happy to help you &#8211; or use our contact form. Call us on +41 71 791 81 00 and we will be happy to help you &#8211; or use our contact form. Would you like to go&nbsp;one step [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":4234,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-7574","page","type-page","status-publish","has-post-thumbnail","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Alpstein Clinic \u2013 Contact<\/title>\n<meta name=\"description\" content=\"Get in touch with us or fill out our online patient questionnaire\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/alpstein-clinic.ch\/en\/contact\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Alpstein Clinic 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