{"id":5368,"date":"2023-09-26T18:10:37","date_gmt":"2023-09-26T15:10:37","guid":{"rendered":"https:\/\/www.vidadent.co.uk\/?page_id=5368"},"modified":"2023-09-28T15:04:59","modified_gmt":"2023-09-28T12:04:59","slug":"patient-referral-form","status":"publish","type":"page","link":"https:\/\/www.vidadent.co.uk\/?page_id=5368","title":{"rendered":"Referral"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"5368\" class=\"elementor elementor-5368\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-f0ba62c elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"f0ba62c\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-775d646\" data-id=\"775d646\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-cb1ee52 elementor-widget elementor-widget-heading\" data-id=\"cb1ee52\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 25-04-2024 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h1 class=\"elementor-heading-title elementor-size-default\">Patient Referral Form\u200b<\/h1>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-8683d4e elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"8683d4e\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-e4524c2\" data-id=\"e4524c2\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-91f5fc3 elementor-widget elementor-widget-wpforms\" data-id=\"91f5fc3\" data-element_type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-5390\"><form id=\"wpforms-form-5390\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"5390\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F5368&#038;wpforms_form_id=5390\" data-token=\"088a18f89a235d10a0d7065211bcc541\"><noscript class=\"wpforms-error-noscript\">\u0414\u043b\u044f \u0437\u0430\u043f\u043e\u043b\u043d\u0435\u043d\u0438\u044f \u0434\u0430\u043d\u043d\u043e\u0439 \u0444\u043e\u0440\u043c\u044b \u0432\u043a\u043b\u044e\u0447\u0438\u0442\u0435 JavaScript \u0432 \u0431\u0440\u0430\u0443\u0437\u0435\u0440\u0435.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-5390-field_44-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_44\">Select practice <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-5390-field_44\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][44]\" required=\"required\"><option value=\"Bethnal Green Road\" >Bethnal Green Road<\/option><\/select><\/div><div id=\"wpforms-5390-field_14-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"14\"><h3 id=\"wpforms-5390-field_14\" name=\"wpforms[fields][14]\">PATIENT DETAILS<\/h3><\/div><div id=\"wpforms-5390-field_39-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"39\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-5390-field_39\">\u041c\u0430\u043a\u0435\u0442<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-5390-field_40-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_40\">Patient First Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5390-field_40\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][40]\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-5390-field_41-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_41\">Patient Surname <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5390-field_41\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][41]\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-5390-field_37-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_37\">Patient Address <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5390-field_37\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][37]\" required><\/div><div id=\"wpforms-5390-field_42-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_42\">Address Line 1<\/label><input type=\"text\" id=\"wpforms-5390-field_42\" class=\"wpforms-field-large\" name=\"wpforms[fields][42]\" ><\/div><div id=\"wpforms-5390-field_43-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_43\">Address Line 2<\/label><input type=\"text\" id=\"wpforms-5390-field_43\" class=\"wpforms-field-large\" name=\"wpforms[fields][43]\" ><\/div><div id=\"wpforms-5390-field_45-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"45\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-5390-field_45\">\u041c\u0430\u043a\u0435\u0442<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-5390-field_46-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_46\"> City<\/label><input type=\"text\" id=\"wpforms-5390-field_46\" class=\"wpforms-field-medium\" name=\"wpforms[fields][46]\" ><\/div><div id=\"wpforms-5390-field_48-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_48\"> Postcode<\/label><input type=\"text\" id=\"wpforms-5390-field_48\" class=\"wpforms-field-medium\" name=\"wpforms[fields][48]\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-5390-field_47-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_47\">County<\/label><input type=\"text\" id=\"wpforms-5390-field_47\" class=\"wpforms-field-medium\" name=\"wpforms[fields][47]\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-5390-field_49-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"49\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-5390-field_49\">\u041c\u0430\u043a\u0435\u0442<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-5390-field_7-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_7\">Patient Date of Birth <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-5390-field_7\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][7][date]\" required><a title=\"\u041e\u0447\u0438\u0441\u0442\u0438\u0442\u044c \u0434\u0430\u0442\u0443\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-5390-field_50-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_50\">Patient Phone Number<\/label><input type=\"tel\" id=\"wpforms-5390-field_50\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][50]\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-5390-field_51-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"51\"><h3 id=\"wpforms-5390-field_51\" name=\"wpforms[fields][51]\">Referring Dentist&#039;s Details<\/h3><\/div><div id=\"wpforms-5390-field_52-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"52\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-5390-field_52\">\u041c\u0430\u043a\u0435\u0442<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-5390-field_53-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_53\">Name of Dentist <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5390-field_53\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][53]\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-5390-field_4-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_4\">Dentist&#039;s Phone Number<\/label><input type=\"tel\" id=\"wpforms-5390-field_4\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][4]\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-5390-field_55-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_55\">Address of Dentist <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5390-field_55\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][55]\" required><\/div><div id=\"wpforms-5390-field_56-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_56\">Address Line 1<\/label><input type=\"text\" id=\"wpforms-5390-field_56\" class=\"wpforms-field-large\" name=\"wpforms[fields][56]\" ><\/div><div id=\"wpforms-5390-field_57-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_57\">Address Line 2<\/label><input type=\"text\" id=\"wpforms-5390-field_57\" class=\"wpforms-field-large\" name=\"wpforms[fields][57]\" ><\/div><div id=\"wpforms-5390-field_58-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"58\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-5390-field_58\">\u041c\u0430\u043a\u0435\u0442 (\u043a\u043e\u043f\u0438\u044f)<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-5390-field_59-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_59\"> City<\/label><input type=\"text\" id=\"wpforms-5390-field_59\" class=\"wpforms-field-medium\" name=\"wpforms[fields][59]\" ><\/div><div id=\"wpforms-5390-field_60-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_60\"> Postcode<\/label><input type=\"text\" id=\"wpforms-5390-field_60\" class=\"wpforms-field-medium\" name=\"wpforms[fields][60]\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-5390-field_61-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"61\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_61\">County<\/label><input type=\"text\" id=\"wpforms-5390-field_61\" class=\"wpforms-field-medium\" name=\"wpforms[fields][61]\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-5390-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_1\">Dentist Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-5390-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-5390-field_62-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"62\"><h3 id=\"wpforms-5390-field_62\" name=\"wpforms[fields][62]\">Referral Details<\/h3><\/div><div id=\"wpforms-5390-field_64-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"64\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_64\">Main Complaint <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-5390-field_64\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][64]\" required><\/textarea><\/div><div id=\"wpforms-5390-field_8-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_8\">Can We Leave a Message?<\/label><ul id=\"wpforms-5390-field_8\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-5390-field_8_1\" name=\"wpforms[fields][8][]\" value=\"Investigate &amp; Treat\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5390-field_8_1\">Investigate &amp; Treat<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-5390-field_8_2\" name=\"wpforms[fields][8][]\" value=\"Opinion Only\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5390-field_8_2\">Opinion Only<\/label><\/li><\/ul><div class=\"wpforms-field-description\">Please tick all that apply<\/div><\/div><div id=\"wpforms-5390-field_66-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"66\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_66\">Relevant Medical Details <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-5390-field_66\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][66]\" required><\/textarea><\/div><div id=\"wpforms-5390-field_67-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"67\"><h3 id=\"wpforms-5390-field_67\" name=\"wpforms[fields][67]\">Clinical Details<\/h3><\/div><div id=\"wpforms-5390-field_68-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"68\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-5390-field_68\">\u041c\u0430\u043a\u0435\u0442<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-5390-field_69-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"69\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_69\">Select pain <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-5390-field_69\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][69]\" required=\"required\"><option value=\"0\" >0<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><\/select><\/div><div id=\"wpforms-5390-field_70-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_70\">Vital <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-5390-field_70\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][70]\" required=\"required\"><option value=\"Yes\" >Yes<\/option><option value=\"No\" >No<\/option><option value=\"?\" >?<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-5390-field_71-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"71\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_71\">Level of swelling <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-5390-field_71\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][71]\" required=\"required\"><option value=\"0\" >0<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><\/select><\/div><div id=\"wpforms-5390-field_73-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"73\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_73\">PA Lesion <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-5390-field_73\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][73]\" required=\"required\"><option value=\"Yes\" >Yes<\/option><option value=\"No\" >No<\/option><option value=\"?\" >?<\/option><\/select><\/div><\/div><\/div><\/div><div id=\"wpforms-5390-field_74-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"74\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_74\">Previous RCT<\/label><ul id=\"wpforms-5390-field_74\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-5390-field_74_1\" name=\"wpforms[fields][74][]\" value=\"Self\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5390-field_74_1\">Self<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-5390-field_74_2\" name=\"wpforms[fields][74][]\" value=\"Paste\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5390-field_74_2\">Paste<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-5390-field_74_3\" name=\"wpforms[fields][74][]\" value=\"Other\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5390-field_74_3\">Other<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-5390-field_74_4\" name=\"wpforms[fields][74][]\" value=\"AG Points\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5390-field_74_4\">AG Points<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-5390-field_74_6\" name=\"wpforms[fields][74][]\" value=\"GP\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5390-field_74_6\">GP<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-5390-field_74_5\" name=\"wpforms[fields][74][]\" value=\"Separated Instrument(s) \/ Obstructions\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5390-field_74_5\">Separated Instrument(s) \/ Obstructions<\/label><\/li><\/ul><\/div><div id=\"wpforms-5390-field_63-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"63\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_63\">Recent Restoration<\/label><textarea id=\"wpforms-5390-field_63\" class=\"wpforms-field-medium\" name=\"wpforms[fields][63]\" ><\/textarea><\/div><div id=\"wpforms-5390-field_75-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"75\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_75\">Further Details<\/label><textarea id=\"wpforms-5390-field_75\" class=\"wpforms-field-medium\" name=\"wpforms[fields][75]\" ><\/textarea><\/div><div id=\"wpforms-5390-field_76-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"76\"><label class=\"wpforms-field-label\" for=\"wpforms-5390-field_76\">File 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