{"id":7574,"date":"2024-11-14T12:55:32","date_gmt":"2024-11-14T12:55:32","guid":{"rendered":"https:\/\/1818-1.pm-domains.de\/contact\/"},"modified":"2025-05-06T11:44:50","modified_gmt":"2025-05-06T11:44:50","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>\n\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>\n<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>\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<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>\n\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 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.\" id=\"form-field-anrede-0\" name=\"form_fields[anrede]\"> <label for=\"form-field-anrede-0\">Mr.<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Mrs.\" id=\"form-field-anrede-1\" name=\"form_fields[anrede]\"> <label for=\"form-field-anrede-1\">Mrs.<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Divers\" id=\"form-field-anrede-2\" name=\"form_fields[anrede]\"> <label for=\"form-field-anrede-2\">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-tel 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<input size=\"1\" type=\"tel\" name=\"form_fields[telefon]\" id=\"form-field-telefon\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\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-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=\"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-coolcaptcha elementor-col-100\">\n\t\t\t\t\t    <input\n\ttype=\"hidden\"\n\tvalue=\"ccgo\"\n\tname=\"form_fields[coolcaptcha]\"\n\t\tid=\"form-field-coolcaptcha\"\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-coolcaptcha\").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>\n\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-440244d e-con-full e-flex e-con e-parent\" data-id=\"440244d\" 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-6807bf4 e-con-full e-flex e-con e-child\" data-id=\"6807bf4\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-feab45a elementor-widget__width-inherit elementor-widget elementor-widget-jet-headline\" data-id=\"feab45a\" 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\">Patient<\/span><\/span><span class=\"jet-headline__part jet-headline__second\"><span class=\"jet-headline__label\">&nbsp;questionnaire<\/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-3eaa275 elementor-widget elementor-widget-spacer\" data-id=\"3eaa275\" 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-fefb867 elementor-button-align-end elementor-widget elementor-widget-form\" data-id=\"fefb867\" 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=\"fefb867\"\/>\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. \">Mr. <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mrs. \">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\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[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=\"Street &amp; nr.\" 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\tZip 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 and 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\">Bangladesh<\/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 Herzegovina<\/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\">Brazil<\/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\">Cameroon<\/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\">Chad<\/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\">Colombia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KM\">Comoros<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CG\">Congo (Brazzaville)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CD\">Congo (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\">Djibouti<\/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\">Estonia<\/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\">Gabon<\/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\">Georgia<\/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\">Jamaica<\/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\">Jordan<\/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\">Kenya<\/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\">Kyrgyzstan<\/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\">Lebanon<\/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\">Libya<\/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\">Maldives<\/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\">Mauritania<\/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\">Micronesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MD\">Moldova<\/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 New Guinea<\/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\">Rwanda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KN\">Saint Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LC\">Saint Lucia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VC\">Saint 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\">Seychelles<\/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\">Singapore<\/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\">Solomon Islands<\/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\">Tajikistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TZ\">Tanzania<\/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\">Tunisia<\/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\">United States<\/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\">Uzbekistan<\/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\">Zambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZW\">Zimbabwe<\/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-tel 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<input size=\"1\" type=\"tel\" name=\"form_fields[phone]\" id=\"form-field-phone\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel 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<input size=\"1\" type=\"tel\" name=\"form_fields[mobile]\" id=\"form-field-mobile\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-hx_Telefonnummer_Firma elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hx_Telefonnummer_Firma\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone company\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[hx_Telefonnummer_Firma]\" id=\"form-field-hx_Telefonnummer_Firma\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\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-Adresse*\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-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>Contact in case of emergency<\/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-tel 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\tTelephone number of emergency contact\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[hx_Phone_Notfall]\" id=\"form-field-hx_Phone_Notfall\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel 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 number of emergency contact\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[hx_Mobile_Notfall]\" id=\"form-field-hx_Mobile_Notfall\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\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-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 number 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\tLand\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 and 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\">Bangladesh<\/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 Herzegovina<\/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\">Brazil<\/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\">Cameroon<\/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\">Chad<\/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\">Colombia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KM\">Comoros<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CG\">Congo (Brazzaville)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CD\">Congo (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\">Djibouti<\/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\">Estonia<\/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\">Gabon<\/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\">Georgia<\/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\">Jamaica<\/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\">Jordan<\/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\">Kenya<\/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\">Kyrgyzstan<\/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\">Lebanon<\/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\">Libya<\/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\">Maldives<\/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\">Mauritania<\/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\">Micronesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MD\">Moldova<\/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 New Guinea<\/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\">Rwanda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KN\">Saint Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LC\">Saint Lucia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VC\">Saint 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\">Seychelles<\/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\">Singapore<\/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\">Solomon Islands<\/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\">Tajikistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TZ\">Tanzania<\/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\">Tunisia<\/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\">United States<\/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\">Uzbekistan<\/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\">Zambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZW\">Zimbabwe<\/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\tPolice nr.\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 town\">\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\tLand\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 and 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\">Bangladesh<\/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 Herzegovina<\/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\">Brazil<\/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\">Cameroon<\/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\">Chad<\/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\">Colombia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KM\">Comoros<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CG\">Congo (Brazzaville)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CD\">Congo (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\">Djibouti<\/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\">Estonia<\/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\">Gabon<\/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\">Georgia<\/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\">Jamaica<\/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\">Jordan<\/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\">Kenya<\/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\">Kyrgyzstan<\/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\">Lebanon<\/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\">Libya<\/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\">Maldives<\/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\">Mauritania<\/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\">Micronesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MD\">Moldova<\/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 New Guinea<\/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\">Rwanda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KN\">Saint Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LC\">Saint Lucia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VC\">Saint 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\">Seychelles<\/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\">Singapore<\/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\">Solomon Islands<\/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\">Tajikistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TZ\">Tanzania<\/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\">Tunisia<\/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\">United States<\/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\">Uzbekistan<\/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\">Zambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZW\">Zimbabwe<\/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>Supplementary 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-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\tPolice nr.\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=\"Street, house number, zip code and town\">\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\tLand\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 and 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\">Bangladesh<\/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 Herzegovina<\/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\">Brazil<\/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\">Cameroon<\/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\">Chad<\/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\">Colombia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KM\">Comoros<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CG\">Congo (Brazzaville)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CD\">Congo (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\">Djibouti<\/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\">Estonia<\/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\">Gabon<\/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\">Georgia<\/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\">Jamaica<\/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\">Jordan<\/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\">Kenya<\/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\">Kyrgyzstan<\/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\">Lebanon<\/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\">Libya<\/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\">Maldives<\/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\">Mauritania<\/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\">Micronesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MD\">Moldova<\/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 New Guinea<\/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\">Rwanda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KN\">Saint Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LC\">Saint Lucia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VC\">Saint 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\">Seychelles<\/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\">Singapore<\/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\">Solomon Islands<\/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\">Tajikistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TZ\">Tanzania<\/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\">Tunisia<\/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\">United States<\/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\">Uzbekistan<\/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\">Zambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZW\">Zimbabwe<\/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>Supplementary dental 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-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\tPolice nr.\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 town\">\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\tLand\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 and 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\">Bangladesh<\/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 Herzegovina<\/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\">Brazil<\/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\">Cameroon<\/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\">Chad<\/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\">Colombia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KM\">Comoros<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CG\">Congo (Brazzaville)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CD\">Congo (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\">Djibouti<\/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\">Estonia<\/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\">Gabon<\/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\">Georgia<\/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\">Jamaica<\/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\">Jordan<\/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\">Kenya<\/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\">Kyrgyzstan<\/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\">Lebanon<\/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\">Libya<\/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\">Maldives<\/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\">Mauritania<\/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\">Micronesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MD\">Moldova<\/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 New Guinea<\/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\">Rwanda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KN\">Saint Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LC\">Saint Lucia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VC\">Saint 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\">Seychelles<\/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\">Singapore<\/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\">Solomon Islands<\/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\">Tajikistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TZ\">Tanzania<\/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\">Tunisia<\/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\">United States<\/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\">Uzbekistan<\/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\">Zambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZW\">Zimbabwe<\/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>Service 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\tService billing\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=\"Invoice dispatch to you (TG)\">Invoice dispatch to you (TG)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Send invoice to your health insurance company (TP)\">Send invoice to your health insurance company (TP)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Send invoice to another body (UV, IV, MV or others)\">Send invoice to another body (UV, IV, MV or others)<\/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=\"General practitioner\" 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>General practitioner<\/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\tVorname\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\tNachname\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=\"Street, house number, zip code and town\">\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\tLand\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 and 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\">Bangladesh<\/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 Herzegovina<\/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\">Brazil<\/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\">Cameroon<\/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\">Chad<\/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\">Colombia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KM\">Comoros<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CG\">Congo (Brazzaville)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CD\">Congo (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\">Djibouti<\/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\">Estonia<\/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\">Gabon<\/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\">Georgia<\/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\">Jamaica<\/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\">Jordan<\/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\">Kenya<\/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\">Kyrgyzstan<\/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\">Lebanon<\/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\">Libya<\/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\">Maldives<\/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\">Mauritania<\/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\">Micronesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MD\">Moldova<\/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 New Guinea<\/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\">Rwanda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KN\">Saint Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LC\">Saint Lucia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VC\">Saint 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\">Seychelles<\/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\">Singapore<\/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\">Solomon Islands<\/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\">Tajikistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TZ\">Tanzania<\/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\">Tunisia<\/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\">United States<\/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\">Uzbekistan<\/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\">Zambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ZW\">Zimbabwe<\/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 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_bd40c0b elementor-col-100\">\n\t\t\t\t\t<h3><strong>State of health - Human: illnesses \/ complaints<\/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 complaints?\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 operations?\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 on family 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 yes; please state how many, which gender and year of birth\">\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 status: Diseases \/ complaints<\/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 complaints?\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 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=\"0\">0<\/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 does your diet look 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\" 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 <\/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 recommended \/ assigned 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 yes, by whom? Please enter the name, address, zip code, city and country of the person.\">\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=\"Advertising\">Advertising<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other media\">Other media<\/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 Infopost?\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 with the practice recall system (reminder 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 the form, you confirm that the information you have provided is correct.\n<br>\nIf there are any changes to your state of health or insurance status during your treatment, please inform us promptly. \n<br>\nIf you fail to keep an appointment and cancel it with less than 24 hours' notice, you will be charged a cancellation fee equivalent 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 above conditions.<\/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 GTC and agree to their validity.<\/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 details and data will be collected and stored electronically to answer my request.<br><br>  <strong>Note:<\/strong> You can revoke your consent at any time for the future by sending an email to <a href=\u201cmailto:info@alpstein-clinic.ch\u201d>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 v27.2 - 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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