{"id":888,"date":"2019-11-04T01:19:35","date_gmt":"2019-11-04T01:19:35","guid":{"rendered":"https:\/\/ferriscan.com\/?page_id=888"},"modified":"2020-05-01T00:19:27","modified_gmt":"2020-05-01T00:19:27","slug":"ferrismart-scanner-details-form","status":"publish","type":"page","link":"https:\/\/ferriscan.com\/ferrismart-scanner-details-form\/","title":{"rendered":"FerriSmart Scanner Details Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"888\" class=\"elementor elementor-888\" data-elementor-settings=\"[]\">\n\t\t\t\t\t\t\t<div class=\"elementor-section-wrap\">\n\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-242f43c elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"242f43c\" data-element_type=\"section\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[{&quot;jet_parallax_layout_image&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;},&quot;_id&quot;:&quot;c83b451&quot;,&quot;jet_parallax_layout_image_tablet&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;},&quot;jet_parallax_layout_image_mobile&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;},&quot;jet_parallax_layout_speed&quot;:{&quot;unit&quot;:&quot;%&quot;,&quot;size&quot;:50,&quot;sizes&quot;:[]},&quot;jet_parallax_layout_type&quot;:&quot;scroll&quot;,&quot;jet_parallax_layout_z_index&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x&quot;:50,&quot;jet_parallax_layout_bg_y&quot;:50,&quot;jet_parallax_layout_bg_size&quot;:&quot;auto&quot;,&quot;jet_parallax_layout_animation_prop&quot;:&quot;transform&quot;,&quot;jet_parallax_layout_on&quot;:[&quot;desktop&quot;,&quot;tablet&quot;],&quot;jet_parallax_layout_direction&quot;:null,&quot;jet_parallax_layout_fx_direction&quot;:null,&quot;jet_parallax_layout_bg_x_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_mobile&quot;:&quot;&quot;}]}\">\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-8e49075\" data-id=\"8e49075\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\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-adc7a47 elementor-section-height-min-height elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"adc7a47\" data-element_type=\"section\" 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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-076d1e4\" data-id=\"076d1e4\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-a4349c1 elementor-widget elementor-widget-spacer\" data-id=\"a4349c1\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\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<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\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-5d95b37 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"5d95b37\" data-element_type=\"section\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[{&quot;jet_parallax_layout_image&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;},&quot;_id&quot;:&quot;69c2be3&quot;,&quot;jet_parallax_layout_image_tablet&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;},&quot;jet_parallax_layout_image_mobile&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;},&quot;jet_parallax_layout_speed&quot;:{&quot;unit&quot;:&quot;%&quot;,&quot;size&quot;:50,&quot;sizes&quot;:[]},&quot;jet_parallax_layout_type&quot;:&quot;scroll&quot;,&quot;jet_parallax_layout_z_index&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x&quot;:50,&quot;jet_parallax_layout_bg_y&quot;:50,&quot;jet_parallax_layout_bg_size&quot;:&quot;auto&quot;,&quot;jet_parallax_layout_animation_prop&quot;:&quot;transform&quot;,&quot;jet_parallax_layout_on&quot;:[&quot;desktop&quot;,&quot;tablet&quot;],&quot;jet_parallax_layout_direction&quot;:null,&quot;jet_parallax_layout_fx_direction&quot;:null,&quot;jet_parallax_layout_bg_x_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_mobile&quot;:&quot;&quot;}]}\">\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-291adf8\" data-id=\"291adf8\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-9cfc764 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"9cfc764\" data-element_type=\"section\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[{&quot;jet_parallax_layout_image&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;},&quot;_id&quot;:&quot;95b17b0&quot;,&quot;jet_parallax_layout_image_tablet&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;},&quot;jet_parallax_layout_image_mobile&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;},&quot;jet_parallax_layout_speed&quot;:{&quot;unit&quot;:&quot;%&quot;,&quot;size&quot;:50,&quot;sizes&quot;:[]},&quot;jet_parallax_layout_type&quot;:&quot;scroll&quot;,&quot;jet_parallax_layout_z_index&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x&quot;:50,&quot;jet_parallax_layout_bg_y&quot;:50,&quot;jet_parallax_layout_bg_size&quot;:&quot;auto&quot;,&quot;jet_parallax_layout_animation_prop&quot;:&quot;transform&quot;,&quot;jet_parallax_layout_on&quot;:[&quot;desktop&quot;,&quot;tablet&quot;],&quot;jet_parallax_layout_direction&quot;:null,&quot;jet_parallax_layout_fx_direction&quot;:null,&quot;jet_parallax_layout_bg_x_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_mobile&quot;:&quot;&quot;}]}\">\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-inner-column elementor-element elementor-element-1bc874c\" data-id=\"1bc874c\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-ce40000 elementor-widget elementor-widget-heading\" data-id=\"ce40000\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">FerriSmart Scanner Details Form<\/h2>\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\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<div class=\"elementor-element elementor-element-542b27c elementor-widget elementor-widget-text-editor\" data-id=\"542b27c\" data-element_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<p><div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_3_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form \" id=\"form_ferrismart-scanner-details-form\"  >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">FerriSmart Scanner Details Form<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"3\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_3\" id=\"frm_hide_fields_3\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"ferrismart-scanner-details-form\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_3\" name=\"frm_submit_entry_3\" value=\"4fe792f5e8\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/888\" \/><div id=\"frm_field_50_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_qh4icy3\" id=\"field_qh4icy3_label\" class=\"frm_primary_label\">Contact Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_qh4icy3\" name=\"item_meta[50]\" value=\"\"  data-reqmsg=\"Contact Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_51_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_ocfup13\" id=\"field_ocfup13_label\" class=\"frm_primary_label\">Email Address\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_ocfup13\" name=\"item_meta[51]\" value=\"\"  data-reqmsg=\"Email Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_52_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_q5qeq2\" id=\"field_q5qeq2_label\" class=\"frm_primary_label\">Position (Job Title)\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_q5qeq2\" name=\"item_meta[52]\" value=\"\"  data-reqmsg=\"Position (Job Title) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_53_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_qj9hz2\" id=\"field_qj9hz2_label\" class=\"frm_primary_label\">Organization\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_qj9hz2\" name=\"item_meta[53]\" value=\"\"  data-reqmsg=\"Organization cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_54_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_2yt7u2\" id=\"field_2yt7u2_label\" class=\"frm_primary_label\">Street Address (include suburb, city, and zip\/post code)\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_2yt7u2\" name=\"item_meta[54]\" value=\"\"  data-reqmsg=\"Street Address (include suburb, city, and zip\/post code) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_55_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_hg9r82\" id=\"field_hg9r82_label\" class=\"frm_primary_label\">Country\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[55]\" id=\"field_hg9r82\"  data-reqmsg=\"Please select your Country.\" aria-required=\"true\" data-invmsg=\"Country is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"Afghanistan\">Afghanistan<\/option><option  value=\"Aland Islands\">Aland Islands<\/option><option  value=\"Albania\">Albania<\/option><option  value=\"Algeria\">Algeria<\/option><option  value=\"American Samoa\">American Samoa<\/option><option  value=\"Andorra\">Andorra<\/option><option  value=\"Angola\">Angola<\/option><option  value=\"Anguilla\">Anguilla<\/option><option  value=\"Antarctica\">Antarctica<\/option><option  value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option><option  value=\"Argentina\">Argentina<\/option><option  value=\"Armenia\">Armenia<\/option><option  value=\"Aruba\">Aruba<\/option><option  value=\"Australia\">Australia<\/option><option  value=\"Austria\">Austria<\/option><option  value=\"Azerbaijan\">Azerbaijan<\/option><option  value=\"Bahamas\">Bahamas<\/option><option  value=\"Bahrain\">Bahrain<\/option><option  value=\"Bangladesh\">Bangladesh<\/option><option  value=\"Barbados\">Barbados<\/option><option  value=\"Belarus\">Belarus<\/option><option  value=\"Belgium\">Belgium<\/option><option  value=\"Belize\">Belize<\/option><option  value=\"Benin\">Benin<\/option><option  value=\"Bermuda\">Bermuda<\/option><option  value=\"Bhutan\">Bhutan<\/option><option  value=\"Bolivia\">Bolivia<\/option><option  value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option  value=\"Botswana\">Botswana<\/option><option  value=\"Bouvet Island\">Bouvet Island<\/option><option  value=\"Brazil\">Brazil<\/option><option  value=\"Brunei\">Brunei<\/option><option  value=\"Bulgaria\">Bulgaria<\/option><option  value=\"Burkina Faso\">Burkina Faso<\/option><option  value=\"Burundi\">Burundi<\/option><option  value=\"Cambodia\">Cambodia<\/option><option  value=\"Cameroon\">Cameroon<\/option><option  value=\"Canada\">Canada<\/option><option  value=\"Cape Verde\">Cape Verde<\/option><option  value=\"Cayman Islands\">Cayman Islands<\/option><option  value=\"Central African Republic\">Central African Republic<\/option><option  value=\"Chad\">Chad<\/option><option  value=\"Chile\">Chile<\/option><option  value=\"China\">China<\/option><option  value=\"Colombia\">Colombia<\/option><option  value=\"Comoros\">Comoros<\/option><option  value=\"Congo\">Congo<\/option><option  value=\"Costa Rica\">Costa Rica<\/option><option  value=\"C\u00f4te d&#039;Ivoire\">C\u00f4te d&#039;Ivoire<\/option><option  value=\"Croatia\">Croatia<\/option><option  value=\"Cuba\">Cuba<\/option><option  value=\"Curacao\">Curacao<\/option><option  value=\"Cyprus\">Cyprus<\/option><option  value=\"Czech Republic\">Czech Republic<\/option><option  value=\"Denmark\">Denmark<\/option><option  value=\"Djibouti\">Djibouti<\/option><option  value=\"Dominica\">Dominica<\/option><option  value=\"Dominican Republic\">Dominican Republic<\/option><option  value=\"East Timor\">East Timor<\/option><option  value=\"Ecuador\">Ecuador<\/option><option  value=\"Egypt\">Egypt<\/option><option  value=\"El Salvador\">El Salvador<\/option><option  value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option  value=\"Eritrea\">Eritrea<\/option><option  value=\"Estonia\">Estonia<\/option><option  value=\"Ethiopia\">Ethiopia<\/option><option  value=\"Fiji\">Fiji<\/option><option  value=\"Finland\">Finland<\/option><option  value=\"France\">France<\/option><option  value=\"French Guiana\">French Guiana<\/option><option  value=\"French Polynesia\">French Polynesia<\/option><option  value=\"Gabon\">Gabon<\/option><option  value=\"Gambia\">Gambia<\/option><option  value=\"Georgia\">Georgia<\/option><option  value=\"Germany\">Germany<\/option><option  value=\"Ghana\">Ghana<\/option><option  value=\"Gibraltar\">Gibraltar<\/option><option  value=\"Greece\">Greece<\/option><option  value=\"Greenland\">Greenland<\/option><option  value=\"Grenada\">Grenada<\/option><option  value=\"Guadeloupe\">Guadeloupe<\/option><option  value=\"Guam\">Guam<\/option><option  value=\"Guatemala\">Guatemala<\/option><option  value=\"Guernsey\">Guernsey<\/option><option  value=\"Guinea\">Guinea<\/option><option  value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option  value=\"Guyana\">Guyana<\/option><option  value=\"Haiti\">Haiti<\/option><option  value=\"Honduras\">Honduras<\/option><option  value=\"Hong Kong\">Hong Kong<\/option><option  value=\"Hungary\">Hungary<\/option><option  value=\"Iceland\">Iceland<\/option><option  value=\"India\">India<\/option><option  value=\"Indonesia\">Indonesia<\/option><option  value=\"Iran\">Iran<\/option><option  value=\"Iraq\">Iraq<\/option><option  value=\"Ireland\">Ireland<\/option><option  value=\"Israel\">Israel<\/option><option  value=\"Italy\">Italy<\/option><option  value=\"Jamaica\">Jamaica<\/option><option  value=\"Japan\">Japan<\/option><option  value=\"Jersey\">Jersey<\/option><option  value=\"Jordan\">Jordan<\/option><option  value=\"Kazakhstan\">Kazakhstan<\/option><option  value=\"Kenya\">Kenya<\/option><option  value=\"Kiribati\">Kiribati<\/option><option  value=\"North Korea\">North Korea<\/option><option  value=\"South Korea\">South Korea<\/option><option  value=\"Kosovo\">Kosovo<\/option><option  value=\"Kuwait\">Kuwait<\/option><option  value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option  value=\"Laos\">Laos<\/option><option  value=\"Latvia\">Latvia<\/option><option  value=\"Lebanon\">Lebanon<\/option><option  value=\"Lesotho\">Lesotho<\/option><option  value=\"Liberia\">Liberia<\/option><option  value=\"Libya\">Libya<\/option><option  value=\"Liechtenstein\">Liechtenstein<\/option><option  value=\"Lithuania\">Lithuania<\/option><option  value=\"Luxembourg\">Luxembourg<\/option><option  value=\"Macao\">Macao<\/option><option  value=\"Macedonia\">Macedonia<\/option><option  value=\"Madagascar\">Madagascar<\/option><option  value=\"Malawi\">Malawi<\/option><option  value=\"Malaysia\">Malaysia<\/option><option  value=\"Maldives\">Maldives<\/option><option  value=\"Mali\">Mali<\/option><option  value=\"Malta\">Malta<\/option><option  value=\"Marshall Islands\">Marshall Islands<\/option><option  value=\"Martinique\">Martinique<\/option><option  value=\"Mauritania\">Mauritania<\/option><option  value=\"Mauritius\">Mauritius<\/option><option  value=\"Mayotte\">Mayotte<\/option><option  value=\"Mexico\">Mexico<\/option><option  value=\"Micronesia\">Micronesia<\/option><option  value=\"Moldova\">Moldova<\/option><option  value=\"Monaco\">Monaco<\/option><option  value=\"Mongolia\">Mongolia<\/option><option  value=\"Montenegro\">Montenegro<\/option><option  value=\"Montserrat\">Montserrat<\/option><option  value=\"Morocco\">Morocco<\/option><option  value=\"Mozambique\">Mozambique<\/option><option  value=\"Myanmar\">Myanmar<\/option><option  value=\"Namibia\">Namibia<\/option><option  value=\"Nauru\">Nauru<\/option><option  value=\"Nepal\">Nepal<\/option><option  value=\"Netherlands\">Netherlands<\/option><option  value=\"New Caledonia\">New Caledonia<\/option><option  value=\"New Zealand\">New Zealand<\/option><option  value=\"Nicaragua\">Nicaragua<\/option><option  value=\"Niger\">Niger<\/option><option  value=\"Nigeria\">Nigeria<\/option><option  value=\"Norway\">Norway<\/option><option  value=\"Northern Mariana Islands\">Northern Mariana Islands<\/option><option  value=\"Oman\">Oman<\/option><option  value=\"Pakistan\">Pakistan<\/option><option  value=\"Palau\">Palau<\/option><option  value=\"Palestine\">Palestine<\/option><option  value=\"Panama\">Panama<\/option><option  value=\"Papua New Guinea\">Papua New Guinea<\/option><option  value=\"Paraguay\">Paraguay<\/option><option  value=\"Peru\">Peru<\/option><option  value=\"Philippines\">Philippines<\/option><option  value=\"Pitcairn\">Pitcairn<\/option><option  value=\"Poland\">Poland<\/option><option  value=\"Portugal\">Portugal<\/option><option  value=\"Puerto Rico\">Puerto Rico<\/option><option  value=\"Qatar\">Qatar<\/option><option  value=\"Romania\">Romania<\/option><option  value=\"Russia\">Russia<\/option><option  value=\"Rwanda\">Rwanda<\/option><option  value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option  value=\"Saint Lucia\">Saint Lucia<\/option><option  value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option><option  value=\"Samoa\">Samoa<\/option><option  value=\"San Marino\">San Marino<\/option><option  value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option><option  value=\"Saudi Arabia\">Saudi Arabia<\/option><option  value=\"Senegal\">Senegal<\/option><option  value=\"Serbia and Montenegro\">Serbia and Montenegro<\/option><option  value=\"Seychelles\">Seychelles<\/option><option  value=\"Sierra Leone\">Sierra Leone<\/option><option  value=\"Singapore\">Singapore<\/option><option  value=\"Slovakia\">Slovakia<\/option><option  value=\"Slovenia\">Slovenia<\/option><option  value=\"Solomon Islands\">Solomon Islands<\/option><option  value=\"Somalia\">Somalia<\/option><option  value=\"South Africa\">South Africa<\/option><option  value=\"South Sudan\">South Sudan<\/option><option  value=\"Spain\">Spain<\/option><option  value=\"Sri Lanka\">Sri Lanka<\/option><option  value=\"Sudan\">Sudan<\/option><option  value=\"Suriname\">Suriname<\/option><option  value=\"Swaziland\">Swaziland<\/option><option  value=\"Sweden\">Sweden<\/option><option  value=\"Switzerland\">Switzerland<\/option><option  value=\"Syria\">Syria<\/option><option  value=\"Taiwan\">Taiwan<\/option><option  value=\"Tajikistan\">Tajikistan<\/option><option  value=\"Tanzania\">Tanzania<\/option><option  value=\"Thailand\">Thailand<\/option><option  value=\"Togo\">Togo<\/option><option  value=\"Tonga\">Tonga<\/option><option  value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option  value=\"Tunisia\">Tunisia<\/option><option  value=\"Turkey\">Turkey<\/option><option  value=\"Turkmenistan\">Turkmenistan<\/option><option  value=\"Tuvalu\">Tuvalu<\/option><option  value=\"Uganda\">Uganda<\/option><option  value=\"Ukraine\">Ukraine<\/option><option  value=\"United Arab Emirates\">United Arab Emirates<\/option><option  value=\"United Kingdom\">United Kingdom<\/option><option  value=\"United States\">United States<\/option><option  value=\"Uruguay\">Uruguay<\/option><option  value=\"Uzbekistan\">Uzbekistan<\/option><option  value=\"Vanuatu\">Vanuatu<\/option><option  value=\"Vatican City\">Vatican City<\/option><option  value=\"Venezuela\">Venezuela<\/option><option  value=\"Vietnam\">Vietnam<\/option><option  value=\"Virgin Islands, British\">Virgin Islands, British<\/option><option  value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option><option  value=\"Yemen\">Yemen<\/option><option  value=\"Zambia\">Zambia<\/option><option  value=\"Zimbabwe\">Zimbabwe<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_80_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_jjf6y\" id=\"field_jjf6y_label\" class=\"frm_primary_label\">Telephone Number (include area code)\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_jjf6y\" name=\"item_meta[80]\" value=\"\"  data-reqmsg=\"Telephone Number (include area code) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_57_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n    <label for=\"field_5zykn2\" id=\"field_5zykn2_label\" class=\"frm_primary_label\">Fax Number (include area code)\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_5zykn2\" name=\"item_meta[57]\" value=\"\"  data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_58_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full vertical_radio\">\r\n    <div  id=\"field_ph5z62_label\" class=\"frm_primary_label\"><b>Will the above person be the Primary Technical Contact?<\/b> &#8211; (Primary Technical Contact is responsible for technical communications with Resonance Health and if applicable, the scanning of a saline bag or test patient to verify the correct acquisition protocol has been set up.)\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_ph5z62_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_58-0\"><label for=\"field_ph5z62-0\"><input type=\"checkbox\" name=\"item_meta[58][]\" id=\"field_ph5z62-0\" value=\"Yes\"  data-reqmsg=\"&lt;b&gt;Will the above person be the Primary Technical Contact?&lt;\/b&gt; - (Primary Technical Contact is responsible for technical communications with Resonance Health and if applicable, the scanning of a saline bag or test patient to verify the correct acquisition protocol has been set up.) cannot be blank.\" data-invmsg=\"&lt;b&gt;Will the above person be the Primary Technical Contact?&lt;\/b&gt; - (Primary Technical Contact is responsible for technical communications with Resonance Health and if applicable, the scanning of a saline bag or test patient to verify the correct acquisition protocol has been set up.) is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_58-1\"><label for=\"field_ph5z62-1\"><input type=\"checkbox\" name=\"item_meta[58][]\" id=\"field_ph5z62-1\" value=\"No\"  data-reqmsg=\"&lt;b&gt;Will the above person be the Primary Technical Contact?&lt;\/b&gt; - (Primary Technical Contact is responsible for technical communications with Resonance Health and if applicable, the scanning of a saline bag or test patient to verify the correct acquisition protocol has been set up.) cannot be blank.\" data-invmsg=\"&lt;b&gt;Will the above person be the Primary Technical Contact?&lt;\/b&gt; - (Primary Technical Contact is responsible for technical communications with Resonance Health and if applicable, the scanning of a saline bag or test patient to verify the correct acquisition protocol has been set up.) is invalid\" aria-invalid=\"false\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_59_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n    <label for=\"field_v2djs2\" id=\"field_v2djs2_label\" class=\"frm_primary_label\">If No, please enter the <b>Contact Name<\/b> of an appropriate Primary Technical Contact below:\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_v2djs2\" name=\"item_meta[59]\" value=\"\"  data-invmsg=\"Name is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_60_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n    <label for=\"field_2adqg2\" id=\"field_2adqg2_label\" class=\"frm_primary_label\">Email Address\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_2adqg2\" name=\"item_meta[60]\" value=\"\"  data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_61_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n    <label for=\"field_dzpfg2\" id=\"field_dzpfg2_label\" class=\"frm_primary_label\">Position (Job Title)\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_dzpfg2\" name=\"item_meta[61]\" value=\"\"  data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_66_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full vertical_radio\">\r\n    <div  id=\"field_97a362_label\" class=\"frm_primary_label\">What type of MRI Scanner will you use?\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_97a362_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_66-0\"><label for=\"field_97a362-0\"><input type=\"checkbox\" name=\"item_meta[66][]\" id=\"field_97a362-0\" value=\"Siemens\"  data-reqmsg=\"What type of MRI Scanner will you use? cannot be blank.\" data-invmsg=\"What type of MRI Scanner will you use? is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> Siemens<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_66-1\"><label for=\"field_97a362-1\"><input type=\"checkbox\" name=\"item_meta[66][]\" id=\"field_97a362-1\" value=\"Philips\"  data-reqmsg=\"What type of MRI Scanner will you use? cannot be blank.\" data-invmsg=\"What type of MRI Scanner will you use? is invalid\" aria-invalid=\"false\"   \/> Philips<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_66-2\"><label for=\"field_97a362-2\"><input type=\"checkbox\" name=\"item_meta[66][]\" id=\"field_97a362-2\" value=\"GE\"  data-reqmsg=\"What type of MRI Scanner will you use? cannot be blank.\" data-invmsg=\"What type of MRI Scanner will you use? is invalid\" aria-invalid=\"false\"   \/> GE<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_66-3\"><label for=\"field_97a362-3\"><input type=\"checkbox\" name=\"item_meta[66][]\" id=\"field_97a362-3\" value=\"Other\"  data-reqmsg=\"What type of MRI Scanner will you use? cannot be blank.\" data-invmsg=\"What type of MRI Scanner will you use? is invalid\" aria-invalid=\"false\"   \/> Other<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_67_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n    <label for=\"field_95rvt2\" id=\"field_95rvt2_label\" class=\"frm_primary_label\">If &#8216;Other&#8217;, please specify manufacturer\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_95rvt2\" name=\"item_meta[67]\" value=\"\"  data-invmsg=\"Name is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_68_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_2z1y72\" id=\"field_2z1y72_label\" class=\"frm_primary_label\">Scanner Model?\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_2z1y72\" name=\"item_meta[68]\" value=\"\"  data-reqmsg=\"Scanner Model? cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_70_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div  id=\"field_i23eo2_label\" class=\"frm_primary_label\">Please confirm your scanner has a field strength of 1.5T\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_i23eo2_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_70-0\"><label for=\"field_i23eo2-0\"><input type=\"checkbox\" name=\"item_meta[70][]\" id=\"field_i23eo2-0\" value=\"Yes\"  data-reqmsg=\"Please confirm your scanner has a field strength of 1.5T cannot be blank.\" data-invmsg=\"Please confirm your scanner has a field strength of 1.5T is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_70-1\"><label for=\"field_i23eo2-1\"><input type=\"checkbox\" name=\"item_meta[70][]\" id=\"field_i23eo2-1\" value=\"No\"  data-reqmsg=\"Please confirm your scanner has a field strength of 1.5T cannot be blank.\" data-invmsg=\"Please confirm your scanner has a field strength of 1.5T is invalid\" aria-invalid=\"false\"   \/> No<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_70-2\"><label for=\"field_i23eo2-2\"><input type=\"checkbox\" name=\"item_meta[70][]\" id=\"field_i23eo2-2\" value=\"Unsure\"  data-reqmsg=\"Please confirm your scanner has a field strength of 1.5T cannot be blank.\" data-invmsg=\"Please confirm your scanner has a field strength of 1.5T is invalid\" aria-invalid=\"false\"   \/> Unsure<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_71_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div  id=\"field_frnna2_label\" class=\"frm_primary_label\">Can your scanner achieve a minimum TE of 6.0ms with a T2-weighted single spin echo (SE) sequence?\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_frnna2_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_71-0\"><label for=\"field_frnna2-0\"><input type=\"checkbox\" name=\"item_meta[71][]\" id=\"field_frnna2-0\" value=\"Yes\"  data-reqmsg=\"Can your scanner achieve a minimum TE of 6.0ms with a T2-weighted single spin echo (SE) sequence? cannot be blank.\" data-invmsg=\"Can your scanner achieve a minimum TE of 6.0ms with a T2-weighted single spin echo (SE) sequence? is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_71-1\"><label for=\"field_frnna2-1\"><input type=\"checkbox\" name=\"item_meta[71][]\" id=\"field_frnna2-1\" value=\"No\"  data-reqmsg=\"Can your scanner achieve a minimum TE of 6.0ms with a T2-weighted single spin echo (SE) sequence? cannot be blank.\" data-invmsg=\"Can your scanner achieve a minimum TE of 6.0ms with a T2-weighted single spin echo (SE) sequence? is invalid\" aria-invalid=\"false\"   \/> No<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_71-2\"><label for=\"field_frnna2-2\"><input type=\"checkbox\" name=\"item_meta[71][]\" id=\"field_frnna2-2\" value=\"Unsure\"  data-reqmsg=\"Can your scanner achieve a minimum TE of 6.0ms with a T2-weighted single spin echo (SE) sequence? cannot be blank.\" data-invmsg=\"Can your scanner achieve a minimum TE of 6.0ms with a T2-weighted single spin echo (SE) sequence? is invalid\" aria-invalid=\"false\"   \/> Unsure<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_77_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_8e3dd\" id=\"field_8e3dd_label\" class=\"frm_primary_label\"><b>Who is your designated Super User?<\/b> (A Super User has the authority to designate user access, set up billing information, and view all processed patient reports)\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_8e3dd\" name=\"item_meta[77]\" value=\"\"  placeholder=\"Contact Name (include Job Title)\" data-reqmsg=\"Please enter the Contact Name of your Super User\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_78_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_dybxx\" id=\"field_dybxx_label\" class=\"frm_primary_label\">Email Address\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_dybxx\" name=\"item_meta[78]\" value=\"\"  data-reqmsg=\"Email Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_79_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_nu83s\" id=\"field_nu83s_label\" class=\"frm_primary_label\">Position (Job Title)\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_nu83s\" name=\"item_meta[79]\" value=\"\"  data-reqmsg=\"Position (Job Title) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_75_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div  id=\"field_tbovj2_label\" class=\"frm_primary_label\"><b>How did you hear about Resonance Health?<\/b>\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_tbovj2_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_75-0\"><label for=\"field_tbovj2-0\"><input type=\"checkbox\" name=\"item_meta[75][]\" id=\"field_tbovj2-0\" value=\"Referring clinician request\"  data-reqmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; cannot be blank.\" data-invmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> Referring clinician request<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_75-1\"><label for=\"field_tbovj2-1\"><input type=\"checkbox\" name=\"item_meta[75][]\" id=\"field_tbovj2-1\" value=\"Conference attendance\"  data-reqmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; cannot be blank.\" data-invmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; is invalid\" aria-invalid=\"false\"   \/> Conference attendance<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_75-2\"><label for=\"field_tbovj2-2\"><input type=\"checkbox\" name=\"item_meta[75][]\" id=\"field_tbovj2-2\" value=\"Publications\"  data-reqmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; cannot be blank.\" data-invmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; is invalid\" aria-invalid=\"false\"   \/> Publications<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_75-3\"><label for=\"field_tbovj2-3\"><input type=\"checkbox\" name=\"item_meta[75][]\" id=\"field_tbovj2-3\" value=\"Personal Research\"  data-reqmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; cannot be blank.\" data-invmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; is invalid\" aria-invalid=\"false\"   \/> Personal Research<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_75-4\"><label for=\"field_tbovj2-4\"><input type=\"checkbox\" name=\"item_meta[75][]\" id=\"field_tbovj2-4\" value=\"Direct contact from Resonance Health\"  data-reqmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; cannot be blank.\" data-invmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; is invalid\" aria-invalid=\"false\"   \/> Direct contact from Resonance Health<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_75-5\"><label for=\"field_tbovj2-5\"><input type=\"checkbox\" name=\"item_meta[75][]\" id=\"field_tbovj2-5\" value=\"Previously involved in a clinical trial\"  data-reqmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; cannot be blank.\" data-invmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; is invalid\" aria-invalid=\"false\"   \/> Previously involved in a clinical trial<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_75-6\"><label for=\"field_tbovj2-6\"><input type=\"checkbox\" name=\"item_meta[75][]\" id=\"field_tbovj2-6\" value=\"Other\"  data-reqmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; cannot be blank.\" data-invmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; is invalid\" aria-invalid=\"false\"   \/> Other<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_76_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div  id=\"field_p89vi2_label\" class=\"frm_primary_label\"><b>How would the cost of the service(s) be funded at your centre?<\/b> (tick any that apply)\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_p89vi2_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_76-0\"><label for=\"field_p89vi2-0\"><input type=\"checkbox\" name=\"item_meta[76][]\" id=\"field_p89vi2-0\" value=\"Covered by the MRI Department\"  data-reqmsg=\"&lt;b&gt;How would the cost of the service(s) be funded at your centre?&lt;\/b&gt; (tick any that apply) cannot be blank.\" data-invmsg=\"&lt;b&gt;How would the cost of the service(s) be funded at your centre?&lt;\/b&gt; (tick any that apply) is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> Covered by the MRI Department<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_76-1\"><label for=\"field_p89vi2-1\"><input type=\"checkbox\" name=\"item_meta[76][]\" id=\"field_p89vi2-1\" value=\"Covered by Government reimbursement\"  data-reqmsg=\"&lt;b&gt;How would the cost of the service(s) be funded at your centre?&lt;\/b&gt; (tick any that apply) cannot be blank.\" data-invmsg=\"&lt;b&gt;How would the cost of the service(s) be funded at your centre?&lt;\/b&gt; (tick any that apply) is invalid\" aria-invalid=\"false\"   \/> Covered by Government reimbursement<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_76-2\"><label for=\"field_p89vi2-2\"><input type=\"checkbox\" name=\"item_meta[76][]\" id=\"field_p89vi2-2\" value=\"Charged to department \/ referring clinician\"  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Form<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"_acf_changed":false,"footnotes":""},"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.2 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>FerriSmart Scanner Details Form<\/title>\n<meta name=\"description\" content=\"Register your interest in our FerriSmart service. 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