{"id":184,"date":"2023-02-20T10:23:54","date_gmt":"2023-02-20T10:23:54","guid":{"rendered":"http:\/\/cosmetique.com.pk\/services\/?page_id=184"},"modified":"2023-03-27T11:27:47","modified_gmt":"2023-03-27T11:27:47","slug":"patient-registration-form","status":"publish","type":"page","link":"https:\/\/cosmetique.com.pk\/services\/patient-registration-form\/","title":{"rendered":"Patient Registration Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"184\" class=\"elementor elementor-184\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2ca1811 elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2ca1811\" data-element_type=\"section\" data-e-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-a19de0f\" data-id=\"a19de0f\" data-element_type=\"column\" data-e-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-6a7a35f elementor-widget elementor-widget-heading\" data-id=\"6a7a35f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Dermatologists, Laser, Hair Transplant, Liposuction &amp; Cosmetic Surgeon<\/h2>\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<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-68bafe1 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"68bafe1\" data-element_type=\"section\" data-e-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-9e696ca\" data-id=\"9e696ca\" data-element_type=\"column\" data-e-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-8789919 elementor-widget elementor-widget-heading\" data-id=\"8789919\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Patient Registration Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-f49698d elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"f49698d\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;button_width&quot;:&quot;60&quot;,&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&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=\"New Form\" aria-label=\"New Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"184\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"f49698d\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Patient Registration Form - Cosmetique\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"184\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-60 elementor-field-required elementor-mark-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\tPatient 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[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-md  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-email elementor-col-20 elementor-field-required elementor-mark-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\tDOB\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"mm\/dd\/yyyy\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-message elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-message\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAge\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[message]\" id=\"form-field-message\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_695ca50 elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_695ca50\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMartial Status\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_695ca50]\" id=\"form-field-field_695ca50\" class=\"elementor-field elementor-size-md  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-field_32515fd elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_32515fd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOccupation\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_32515fd]\" id=\"form-field-field_32515fd\" class=\"elementor-field elementor-size-md  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-field_436389b elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_436389b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGender\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=\"Male\" id=\"form-field-field_436389b-0\" name=\"form_fields[field_436389b]\" required=\"required\"> <label for=\"form-field-field_436389b-0\">Male<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Female\" id=\"form-field-field_436389b-1\" name=\"form_fields[field_436389b]\" required=\"required\"> <label for=\"form-field-field_436389b-1\">Female<\/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-field_78c5683 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_78c5683\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_78c5683]\" id=\"form-field-field_78c5683\" class=\"elementor-field elementor-size-md  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-field_2e114ca elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2e114ca\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone No: Residential:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_2e114ca]\" id=\"form-field-field_2e114ca\" class=\"elementor-field elementor-size-md  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-field_40e51e0 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_40e51e0\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone No: Office:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_40e51e0]\" id=\"form-field-field_40e51e0\" class=\"elementor-field elementor-size-md  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-field_6de3ffc elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6de3ffc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone No: Mobile:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_6de3ffc]\" id=\"form-field-field_6de3ffc\" class=\"elementor-field elementor-size-md  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-field_d6d7d7b elementor-col-66 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d6d7d7b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmergency Contact Preson\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d6d7d7b]\" id=\"form-field-field_d6d7d7b\" class=\"elementor-field elementor-size-md  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-field_8baf7e5 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8baf7e5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tReferred By: \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_8baf7e5]\" id=\"form-field-field_8baf7e5\" class=\"elementor-field elementor-size-md  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-field_65dcda5 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_65dcda5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tComplaint\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_65dcda5]\" id=\"form-field-field_65dcda5\" class=\"elementor-field elementor-size-md  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-field_261bf7a elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_261bf7a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhere Site\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_261bf7a]\" id=\"form-field-field_261bf7a\" class=\"elementor-field elementor-size-md  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-field_fc41ff6 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fc41ff6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDuration \/ For How Long\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_fc41ff6]\" id=\"form-field-field_fc41ff6\" class=\"elementor-field elementor-size-md  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-field_bdb1221 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_bdb1221]\" id=\"form-field-field_bdb1221\" class=\"elementor-field elementor-size-md  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-field_d9ec148 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d9ec148]\" id=\"form-field-field_d9ec148\" class=\"elementor-field elementor-size-md  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-field_598ee74 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_598ee74]\" id=\"form-field-field_598ee74\" class=\"elementor-field elementor-size-md  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-textarea elementor-field-group elementor-column elementor-field-group-field_dcf23af elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dcf23af\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPast Diseases \/ Surgeries \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[field_dcf23af]\" id=\"form-field-field_dcf23af\" rows=\"4\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_4b4c017 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4b4c017\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMedicines That You Are Taking Now\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[field_4b4c017]\" id=\"form-field-field_4b4c017\" rows=\"4\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_09068d1 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_09068d1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAny Disease In Parents\/Brothers\/Sisters (e.g. Asthama, Eczema, Diabetes, Highblood Pressure, etc.)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[field_09068d1]\" id=\"form-field-field_09068d1\" rows=\"4\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_ae84bf4 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ae84bf4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMedicines That You Took In The Past\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[field_ae84bf4]\" id=\"form-field-field_ae84bf4\" rows=\"4\" required=\"required\"><\/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-field_9fe423d elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9fe423d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDisease Of Brains And Nerves :\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_9fe423d]\" id=\"form-field-field_9fe423d\" class=\"elementor-field elementor-size-md  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-field_40729c1 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_40729c1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHeart Disease \/ Blood Pressure etc :\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_40729c1]\" id=\"form-field-field_40729c1\" class=\"elementor-field elementor-size-md  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-field_fb9cfc9 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fb9cfc9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAbdominal Problems (Acidity, Ulcer, Diarrhea, Constipation etc :   )\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_fb9cfc9]\" id=\"form-field-field_fb9cfc9\" class=\"elementor-field elementor-size-md  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-field_ca388f8 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ca388f8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLiverr Disease \/ Hep.B \/ Hep.C etc :\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ca388f8]\" id=\"form-field-field_ca388f8\" class=\"elementor-field elementor-size-md  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-field_38e5601 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_38e5601\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLung Diseases \/ Cough \/ Asthama : \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_38e5601]\" id=\"form-field-field_38e5601\" class=\"elementor-field elementor-size-md  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-field_bc95809 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bc95809\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tKidney Diseases \/ Stones etc :\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_bc95809]\" id=\"form-field-field_bc95809\" class=\"elementor-field elementor-size-md  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-field_5e6ee55 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5e6ee55\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAllergies To Anything \/ Fever \/ Lupus \/ AIDS :\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5e6ee55]\" id=\"form-field-field_5e6ee55\" class=\"elementor-field elementor-size-md  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-field_66460de elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_66460de\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDiabetes \/ Blood Sugar \/ Thyroid Problems : \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_66460de]\" id=\"form-field-field_66460de\" class=\"elementor-field elementor-size-md  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-field_e888764 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e888764\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIrregular Periods \/ Problems With Private Parts \/ Urine Problems : \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e888764]\" id=\"form-field-field_e888764\" class=\"elementor-field elementor-size-md  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-field_7a95339 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7a95339\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMuscle Problems \/ Joints Painns : \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7a95339]\" id=\"form-field-field_7a95339\" class=\"elementor-field elementor-size-md  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-field_cf86212 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cf86212\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSexual Problems : \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_cf86212]\" id=\"form-field-field_cf86212\" class=\"elementor-field elementor-size-md  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-field_f594c68 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f594c68\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo You Drink Alcohol :\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f594c68]\" id=\"form-field-field_f594c68\" class=\"elementor-field elementor-size-md  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-field_70922c9 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_70922c9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo You Smoke :\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_70922c9]\" id=\"form-field-field_70922c9\" class=\"elementor-field elementor-size-md  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-number elementor-field-group elementor-column elementor-field-group-field_26b4174 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_26b4174\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow Many Cigrattes Per Day :\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_26b4174]\" id=\"form-field-field_26b4174\" class=\"elementor-field elementor-size-md  elementor-field-textual\" min=\"\" max=\"\" >\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-60 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-md 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\">Register Now<\/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\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Dermatologists, Laser, Hair Transplant, Liposuction &#038; Cosmetic Surgeon Patient Registration Form<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-184","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Patient Registration Form - Cosmetique<\/title>\n<meta name=\"robots\" content=\"noindex, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Patient Registration Form - Cosmetique\" \/>\n<meta property=\"og:description\" content=\"Dermatologists, Laser, Hair Transplant, Liposuction &#038; Cosmetic Surgeon Patient Registration Form\" \/>\n<meta property=\"og:url\" content=\"https:\/\/cosmetique.com.pk\/services\/patient-registration-form\/\" \/>\n<meta property=\"og:site_name\" content=\"Cosmetique\" \/>\n<meta property=\"article:modified_time\" content=\"2023-03-27T11:27:47+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/cosmetique.com.pk\\\/services\\\/patient-registration-form\\\/\",\"url\":\"https:\\\/\\\/cosmetique.com.pk\\\/services\\\/patient-registration-form\\\/\",\"name\":\"Patient Registration Form - Cosmetique\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/cosmetique.com.pk\\\/services\\\/#website\"},\"datePublished\":\"2023-02-20T10:23:54+00:00\",\"dateModified\":\"2023-03-27T11:27:47+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/cosmetique.com.pk\\\/services\\\/patient-registration-form\\\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/cosmetique.com.pk\\\/services\\\/patient-registration-form\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/cosmetique.com.pk\\\/services\\\/patient-registration-form\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/cosmetique.com.pk\\\/services\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Patient Registration Form\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/cosmetique.com.pk\\\/services\\\/#website\",\"url\":\"https:\\\/\\\/cosmetique.com.pk\\\/services\\\/\",\"name\":\"Cosmetique\",\"description\":\"\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\\\/\\\/cosmetique.com.pk\\\/services\\\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Patient Registration Form - Cosmetique","robots":{"index":"noindex","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"og_locale":"en_US","og_type":"article","og_title":"Patient Registration Form - Cosmetique","og_description":"Dermatologists, Laser, Hair Transplant, Liposuction &#038; Cosmetic Surgeon Patient Registration Form","og_url":"https:\/\/cosmetique.com.pk\/services\/patient-registration-form\/","og_site_name":"Cosmetique","article_modified_time":"2023-03-27T11:27:47+00:00","twitter_card":"summary_large_image","schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/cosmetique.com.pk\/services\/patient-registration-form\/","url":"https:\/\/cosmetique.com.pk\/services\/patient-registration-form\/","name":"Patient Registration Form - Cosmetique","isPartOf":{"@id":"https:\/\/cosmetique.com.pk\/services\/#website"},"datePublished":"2023-02-20T10:23:54+00:00","dateModified":"2023-03-27T11:27:47+00:00","breadcrumb":{"@id":"https:\/\/cosmetique.com.pk\/services\/patient-registration-form\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/cosmetique.com.pk\/services\/patient-registration-form\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/cosmetique.com.pk\/services\/patient-registration-form\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/cosmetique.com.pk\/services\/"},{"@type":"ListItem","position":2,"name":"Patient Registration Form"}]},{"@type":"WebSite","@id":"https:\/\/cosmetique.com.pk\/services\/#website","url":"https:\/\/cosmetique.com.pk\/services\/","name":"Cosmetique","description":"","potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/cosmetique.com.pk\/services\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"}]}},"_links":{"self":[{"href":"https:\/\/cosmetique.com.pk\/services\/wp-json\/wp\/v2\/pages\/184","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/cosmetique.com.pk\/services\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/cosmetique.com.pk\/services\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/cosmetique.com.pk\/services\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/cosmetique.com.pk\/services\/wp-json\/wp\/v2\/comments?post=184"}],"version-history":[{"count":0,"href":"https:\/\/cosmetique.com.pk\/services\/wp-json\/wp\/v2\/pages\/184\/revisions"}],"wp:attachment":[{"href":"https:\/\/cosmetique.com.pk\/services\/wp-json\/wp\/v2\/media?parent=184"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}