{"id":11924,"date":"2021-08-16T10:40:22","date_gmt":"2021-08-16T10:40:22","guid":{"rendered":"https:\/\/ssmc.ae\/?page_id=11924"},"modified":"2025-03-13T11:11:31","modified_gmt":"2025-03-13T07:11:31","slug":"referral-patient","status":"publish","type":"page","link":"https:\/\/ssmc.ae\/referral-patient\/","title":{"rendered":"Referral Patient"},"content":{"rendered":"<style>\r\nbody{<br \/>\r\n    min-height: 100vh;<br \/>\r\n    display: flex;<br \/>\r\n    flex-direction: column;<br \/>\r\n}<\/p>\r\n<p>footer{<br \/>\r\nheight:100%<br \/>\r\n}<br \/>\r\n<\/style>\r\n\r\n<form action=\"\" class=\"aaa-form aaa-referral-patient-form\" method=\"POST\" enctype=\"multipart\/form-data\"><input name=\"_nonce\" value=\"b866b3e3f2\" type=\"hidden\" \/><style>.form-actions[data-step=\"2\"]{display:none!important}<\/style><div class=\"aaa-form-step step-1\"><div class=\"aaa-verify-field\"><div class=\"referral-account\"><div><h4>Don't have an referral account?<\/h4><small>Click on the button to register for a new account<\/small><\/div><br\/><a class=\"btn btn-primary\" href=\"\/referral-register\/\">Register a new account<\/a><\/div><hr\/><div class=\"aaa-form-group\"><div class=\"control-group control-group-text control-group-code \" >\n    <label  for=\"code\">Registered email address<span class=\"required\">*<\/span><\/label>    <input name=\"code\" placeholder=\"Enter your email address...\" required=\"1\" value=\"\" type=\"text\" \/>\n<\/div><\/div><\/div><\/div><div class=\"aaa-form-step step-2\"><h2>Patient Information<\/h2><div class=\"aaa-form-group\"><div class=\"control-group control-group-text control-group-patient_fname \" style=\"max-width:200px\">\n    <label  for=\"patient_fname\">Patient First Name<span class=\"required\">*<\/span><\/label>    <input name=\"patient_fname\" required=\"1\" value=\"\" type=\"text\" \/>\n<\/div><div class=\"control-group control-group-text control-group-patient_lname \" style=\"max-width:200px\">\n    <label  for=\"patient_lname\">Patient Last Name<span class=\"required\">*<\/span><\/label>    <input name=\"patient_lname\" required=\"1\" value=\"\" type=\"text\" \/>\n<\/div><div class=\"control-group control-group-text control-group-mrn \" >\n    <label  for=\"mrn\">SSMC MRN Hospital Number (If Available)<\/label>    <input name=\"mrn\" value=\"\" type=\"text\" \/>\n<\/div><\/div><div class=\"aaa-form-group\"><div class=\"control-group control-group-radios control-group-gender\" >\n    <label  for=\"gender\">Gender<span class=\"required\">*<\/span><\/label>    <div class=\"checkbox-wrap radio-wrap\">\n                    <div>\n                <input type=\"radio\" type=\"radios\" name=\"gender\" required=\"1\" value=\"male\" >\n                <label class=\"radio-label\">Male<\/label>\n            <\/div>\n                    <div>\n                <input type=\"radio\" type=\"radios\" name=\"gender\" required=\"1\" value=\"female\" >\n                <label class=\"radio-label\">Female<\/label>\n            <\/div>\n            <\/div>\n<\/div><div class=\"control-group control-group-text control-group-emirates_id \" >\n    <label  for=\"emirates_id\">Emirates ID\/Passport No.<\/label>    <input type=\"text\" name=\"emirates_id\" value=\"\" \/>\n<\/div><\/div><div class=\"aaa-form-group\"><div class=\"control-group control-group-text control-group-patient_email \" >\n    <label  for=\"patient_email\">Patient\/Guardian Email<\/label>    <input name=\"patient_email\" value=\"\" type=\"text\" \/>\n<\/div><div class=\"control-group control-group-text control-group-address \" >\n    <label  for=\"address\">Address<\/label>    <input type=\"text\" name=\"address\" value=\"\" \/>\n<\/div><\/div><div class=\"aaa-form-group\"><div class=\"control-group\">\n    <label  for=\"country\">Country<span class=\"required\">*<\/span><\/label>    <div class=\"select-wrap\">\n        <select name=\"country\" required=\"1\" type=\"text\">\n                            <option value=\"\" selected=\"selected\">Select a Country...<\/option>\n                            <option value=\"AE\" >United Arab Emirates<\/option>\n                            <option value=\"SA\" >Saudi Arabia<\/option>\n                            <option value=\"US\" >United States<\/option>\n                            <option value=\"CA\" >Canada<\/option>\n                            <option value=\"GB\" >United Kingdom<\/option>\n                            <option value=\" \" >---------------<\/option>\n                            <option value=\"AF\" >Afghanistan<\/option>\n                            <option value=\"AL\" >Albania<\/option>\n                            <option value=\"DZ\" >Algeria<\/option>\n                            <option value=\"AS\" >American Samoa<\/option>\n                            <option value=\"AD\" >Andorra<\/option>\n                            <option value=\"AO\" >Angola<\/option>\n                            <option value=\"AI\" >Anguilla<\/option>\n                            <option value=\"AQ\" >Antarctica<\/option>\n                            <option value=\"AG\" >Antigua and Barbuda<\/option>\n                            <option value=\"AR\" >Argentina<\/option>\n                            <option value=\"AM\" >Armenia<\/option>\n                            <option value=\"AW\" >Aruba<\/option>\n                            <option value=\"AU\" >Australia<\/option>\n                            <option value=\"AT\" >Austria<\/option>\n                            <option value=\"AZ\" >Azerbaijan<\/option>\n                            <option value=\"BS\" >Bahamas<\/option>\n                            <option value=\"BH\" >Bahrain<\/option>\n                            <option value=\"BD\" >Bangladesh<\/option>\n                            <option value=\"BB\" >Barbados<\/option>\n                            <option value=\"BY\" >Belarus<\/option>\n                            <option value=\"BE\" >Belgium<\/option>\n                            <option value=\"BZ\" >Belize<\/option>\n                            <option value=\"BJ\" >Benin<\/option>\n                            <option value=\"BM\" >Bermuda<\/option>\n                            <option value=\"BT\" >Bhutan<\/option>\n                            <option value=\"BO\" >Bolivia<\/option>\n                            <option value=\"BA\" >Bosnia and Herzegowina<\/option>\n                            <option value=\"BW\" >Botswana<\/option>\n                            <option value=\"BV\" >Bouvet Island<\/option>\n                            <option value=\"BR\" >Brazil<\/option>\n                            <option value=\"IO\" >British Indian Ocean Territory<\/option>\n                            <option value=\"BN\" >Brunei Darussalam<\/option>\n                            <option value=\"BG\" >Bulgaria<\/option>\n                            <option value=\"BF\" >Burkina Faso<\/option>\n                            <option value=\"BI\" >Burundi<\/option>\n                            <option value=\"KH\" >Cambodia<\/option>\n                            <option value=\"CM\" >Cameroon<\/option>\n                            <option value=\"CV\" >Cape Verde<\/option>\n                            <option value=\"KY\" >Cayman Islands<\/option>\n                            <option value=\"CF\" >Central African Republic<\/option>\n                            <option value=\"TD\" >Chad<\/option>\n                            <option value=\"CL\" >Chile<\/option>\n                            <option value=\"CN\" >China<\/option>\n                            <option value=\"CX\" >Christmas Island<\/option>\n                            <option value=\"CC\" >Cocos (Keeling) Islands<\/option>\n                            <option value=\"CO\" >Colombia<\/option>\n                            <option value=\"KM\" >Comoros<\/option>\n                            <option value=\"CG\" >Congo<\/option>\n                            <option value=\"CD\" >Congo, the Democratic Republic of the<\/option>\n                            <option value=\"CK\" >Cook Islands<\/option>\n                            <option value=\"CR\" >Costa Rica<\/option>\n                            <option value=\"CI\" >Cote d'Ivoire<\/option>\n                            <option value=\"HR\" >Croatia (Hrvatska)<\/option>\n                            <option value=\"CU\" >Cuba<\/option>\n                            <option value=\"CY\" >Cyprus<\/option>\n                            <option value=\"CZ\" >Czech Republic<\/option>\n                            <option value=\"DK\" >Denmark<\/option>\n                            <option value=\"DJ\" >Djibouti<\/option>\n                            <option value=\"DM\" >Dominica<\/option>\n                            <option value=\"DO\" >Dominican Republic<\/option>\n                            <option value=\"TP\" >East Timor<\/option>\n                            <option value=\"EC\" >Ecuador<\/option>\n                            <option value=\"EG\" >Egypt<\/option>\n                            <option value=\"SV\" >El Salvador<\/option>\n                            <option value=\"GQ\" >Equatorial Guinea<\/option>\n                            <option value=\"ER\" >Eritrea<\/option>\n                            <option value=\"EE\" >Estonia<\/option>\n                            <option value=\"ET\" >Ethiopia<\/option>\n                            <option value=\"FK\" >Falkland Islands (Malvinas)<\/option>\n                            <option value=\"FO\" >Faroe Islands<\/option>\n                            <option value=\"FJ\" >Fiji<\/option>\n                            <option value=\"FI\" >Finland<\/option>\n                            <option value=\"FR\" >France<\/option>\n                            <option value=\"FX\" >France, Metropolitan<\/option>\n                            <option value=\"GF\" >French Guiana<\/option>\n                            <option value=\"PF\" >French Polynesia<\/option>\n                            <option value=\"TF\" >French Southern Territories<\/option>\n                            <option value=\"GA\" >Gabon<\/option>\n                            <option value=\"GM\" >Gambia<\/option>\n                            <option value=\"GE\" >Georgia<\/option>\n                            <option value=\"DE\" >Germany<\/option>\n                            <option value=\"GH\" >Ghana<\/option>\n                            <option value=\"GI\" >Gibraltar<\/option>\n                            <option value=\"GR\" >Greece<\/option>\n                            <option value=\"GL\" >Greenland<\/option>\n                            <option value=\"GD\" >Grenada<\/option>\n                            <option value=\"GP\" >Guadeloupe<\/option>\n                            <option value=\"GU\" >Guam<\/option>\n                            <option value=\"GT\" >Guatemala<\/option>\n                            <option value=\"GN\" >Guinea<\/option>\n                            <option value=\"GW\" >Guinea-Bissau<\/option>\n                            <option value=\"GY\" >Guyana<\/option>\n                            <option value=\"HT\" >Haiti<\/option>\n                            <option value=\"HM\" >Heard and Mc Donald Islands<\/option>\n                            <option value=\"VA\" >Holy See (Vatican City State)<\/option>\n                            <option value=\"HN\" >Honduras<\/option>\n                            <option value=\"HK\" >Hong Kong<\/option>\n                            <option value=\"HU\" >Hungary<\/option>\n                            <option value=\"IS\" >Iceland<\/option>\n                            <option value=\"IN\" >India<\/option>\n                            <option value=\"ID\" >Indonesia<\/option>\n                            <option value=\"IR\" >Iran<\/option>\n                            <option value=\"IQ\" >Iraq<\/option>\n                            <option value=\"IE\" >Ireland<\/option>\n                            <option value=\"IL\" >Israel<\/option>\n                            <option value=\"IT\" >Italy<\/option>\n                            <option value=\"JM\" >Jamaica<\/option>\n                            <option value=\"JP\" >Japan<\/option>\n                            <option value=\"JO\" >Jordan<\/option>\n                            <option value=\"KZ\" >Kazakhstan<\/option>\n                            <option value=\"KE\" >Kenya<\/option>\n                            <option value=\"KI\" >Kiribati<\/option>\n                            <option value=\"KP\" >Korea, Democratic People's Republic of<\/option>\n                            <option value=\"KR\" >Korea, Republic of<\/option>\n                            <option value=\"KW\" >Kuwait<\/option>\n                            <option value=\"KG\" >Kyrgyzstan<\/option>\n                            <option value=\"LA\" >Lao People's Democratic Republic<\/option>\n                            <option value=\"LV\" >Latvia<\/option>\n                            <option value=\"LB\" >Lebanon<\/option>\n                            <option value=\"LS\" >Lesotho<\/option>\n                            <option value=\"LR\" >Liberia<\/option>\n                            <option value=\"LY\" >Libyan Arab Jamahiriya<\/option>\n                            <option value=\"LI\" >Liechtenstein<\/option>\n                            <option value=\"LT\" >Lithuania<\/option>\n                            <option value=\"LU\" >Luxembourg<\/option>\n                            <option value=\"MO\" >Macau<\/option>\n                            <option value=\"MK\" >Macedonia, The Former Yugoslav Republic of<\/option>\n                            <option value=\"MG\" >Madagascar<\/option>\n                            <option value=\"MW\" >Malawi<\/option>\n                            <option value=\"MY\" >Malaysia<\/option>\n                            <option value=\"MV\" >Maldives<\/option>\n                            <option value=\"ML\" >Mali<\/option>\n                            <option value=\"MT\" >Malta<\/option>\n                            <option value=\"MH\" >Marshall Islands<\/option>\n                            <option value=\"MQ\" >Martinique<\/option>\n                            <option value=\"MR\" >Mauritania<\/option>\n                            <option value=\"MU\" >Mauritius<\/option>\n                            <option value=\"YT\" >Mayotte<\/option>\n                            <option value=\"MX\" >Mexico<\/option>\n                            <option value=\"FM\" >Micronesia, Federated States of<\/option>\n                            <option value=\"MD\" >Moldova, Republic of<\/option>\n                            <option value=\"MC\" >Monaco<\/option>\n                            <option value=\"MN\" >Mongolia<\/option>\n                            <option value=\"MS\" >Montserrat<\/option>\n                            <option value=\"MA\" >Morocco<\/option>\n                            <option value=\"MZ\" >Mozambique<\/option>\n                            <option value=\"MM\" >Myanmar<\/option>\n                            <option value=\"NA\" >Namibia<\/option>\n                            <option value=\"NR\" >Nauru<\/option>\n                            <option value=\"NP\" >Nepal<\/option>\n                            <option value=\"NL\" >Netherlands<\/option>\n                            <option value=\"AN\" >Netherlands Antilles<\/option>\n                            <option value=\"NC\" >New Caledonia<\/option>\n                            <option value=\"NZ\" >New Zealand<\/option>\n                            <option value=\"NI\" >Nicaragua<\/option>\n                            <option value=\"NE\" >Niger<\/option>\n                            <option value=\"NG\" >Nigeria<\/option>\n                            <option value=\"NU\" >Niue<\/option>\n                            <option value=\"NF\" >Norfolk Island<\/option>\n                            <option value=\"MP\" >Northern Mariana Islands<\/option>\n                            <option value=\"NO\" >Norway<\/option>\n                            <option value=\"OM\" >Oman<\/option>\n                            <option value=\"PS\" >Palestine<\/option>\n                            <option value=\"PK\" >Pakistan<\/option>\n                            <option value=\"PW\" >Palau<\/option>\n                            <option value=\"PA\" >Panama<\/option>\n                            <option value=\"PG\" >Papua New Guinea<\/option>\n                            <option value=\"PY\" >Paraguay<\/option>\n                            <option value=\"PE\" >Peru<\/option>\n                            <option value=\"PH\" >Philippines<\/option>\n                            <option value=\"PN\" >Pitcairn<\/option>\n                            <option value=\"PL\" >Poland<\/option>\n                            <option value=\"PT\" >Portugal<\/option>\n                            <option value=\"PR\" >Puerto Rico<\/option>\n                            <option value=\"QA\" >Qatar<\/option>\n                            <option value=\"RE\" >Reunion<\/option>\n                            <option value=\"RO\" >Romania<\/option>\n                            <option value=\"RU\" >Russian Federation<\/option>\n                            <option value=\"RW\" >Rwanda<\/option>\n                            <option value=\"KN\" >Saint Kitts and Nevis<\/option>\n                            <option value=\"LC\" >Saint LUCIA<\/option>\n                            <option value=\"VC\" >Saint Vincent and the Grenadines<\/option>\n                            <option value=\"WS\" >Samoa<\/option>\n                            <option value=\"SM\" >San Marino<\/option>\n                            <option value=\"ST\" >Sao Tome and Principe<\/option>\n                            <option value=\"SN\" >Senegal<\/option>\n                            <option value=\"SC\" >Seychelles<\/option>\n                            <option value=\"SL\" >Sierra Leone<\/option>\n                            <option value=\"SG\" >Singapore<\/option>\n                            <option value=\"SK\" >Slovakia (Slovak Republic)<\/option>\n                            <option value=\"SI\" >Slovenia<\/option>\n                            <option value=\"SB\" >Solomon Islands<\/option>\n                            <option value=\"SO\" >Somalia<\/option>\n                            <option value=\"ZA\" >South Africa<\/option>\n                            <option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option>\n                            <option value=\"ES\" >Spain<\/option>\n                            <option value=\"LK\" >Sri Lanka<\/option>\n                            <option value=\"SH\" >St. Helena<\/option>\n                            <option value=\"PM\" >St. Pierre and Miquelon<\/option>\n                            <option value=\"SD\" >Sudan<\/option>\n                            <option value=\"SR\" >Suriname<\/option>\n                            <option value=\"SJ\" >Svalbard and Jan Mayen Islands<\/option>\n                            <option value=\"SZ\" >Swaziland<\/option>\n                            <option value=\"SE\" >Sweden<\/option>\n                            <option value=\"CH\" >Switzerland<\/option>\n                            <option value=\"SY\" >Syrian Arab Republic<\/option>\n                            <option value=\"TW\" >Taiwan<\/option>\n                            <option value=\"TJ\" >Tajikistan<\/option>\n                            <option value=\"TZ\" >Tanzania, United Republic of<\/option>\n                            <option value=\"TH\" >Thailand<\/option>\n                            <option value=\"TG\" >Togo<\/option>\n                            <option value=\"TK\" >Tokelau<\/option>\n                            <option value=\"TO\" >Tonga<\/option>\n                            <option value=\"TT\" >Trinidad and Tobago<\/option>\n                            <option value=\"TN\" >Tunisia<\/option>\n                            <option value=\"TR\" >Turkey<\/option>\n                            <option value=\"TM\" >Turkmenistan<\/option>\n                            <option value=\"TC\" >Turks and Caicos Islands<\/option>\n                            <option value=\"TV\" >Tuvalu<\/option>\n                            <option value=\"UG\" >Uganda<\/option>\n                            <option value=\"UA\" >Ukraine<\/option>\n                            <option value=\"UM\" >United States Minor Outlying Islands<\/option>\n                            <option value=\"UY\" >Uruguay<\/option>\n                            <option value=\"UZ\" >Uzbekistan<\/option>\n                            <option value=\"VU\" >Vanuatu<\/option>\n                            <option value=\"VE\" >Venezuela<\/option>\n                            <option value=\"VN\" >Viet Nam<\/option>\n                            <option value=\"VG\" >Virgin Islands (British)<\/option>\n                            <option value=\"VI\" >Virgin Islands (U.S.)<\/option>\n                            <option value=\"WF\" >Wallis and Futuna Islands<\/option>\n                            <option value=\"EH\" >Western Sahara<\/option>\n                            <option value=\"YE\" >Yemen<\/option>\n                            <option value=\"YU\" >Yugoslavia<\/option>\n                            <option value=\"ZM\" >Zambia<\/option>\n                            <option value=\"ZW\" >Zimbabwe<\/option>\n                    <\/select>\n    <\/div>\n<\/div><div class=\"control-group control-group-text control-group-city \" >\n    <label  for=\"city\">City<span class=\"required\">*<\/span><\/label>    <input type=\"text\" name=\"city\" required=\"1\" value=\"\" \/>\n<\/div><\/div><div class=\"aaa-form-group\"><div class=\"control-group control-group-text control-group-phone \" >\n    <label  for=\"phone\">Mobile Number<span class=\"required\">*<\/span><\/label>    <input type=\"tel\" name=\"phone\" required=\"1\" value=\"\" \/>\n<\/div><div class=\"control-group control-group-text control-group-alternate_phone \" >\n    <label  for=\"alternate_phone\">Alternate Phone<\/label>    <input type=\"tel\" name=\"alternate_phone\" value=\"\" \/>\n<\/div><\/div><div class=\"aaa-form-group\"><div class=\"control-group control-group-text control-group-parent_name \" >\n    <label  for=\"parent_name\">Guardian Name (if minor)<\/label>    <input type=\"text\" name=\"parent_name\" value=\"\" \/>\n<\/div><div class=\"control-group control-group-text control-group-patient_insurance \" >\n    <label  for=\"patient_insurance\">Patient Insurance Information (If Available)<\/label>    <input type=\"text\" name=\"patient_insurance\" value=\"\" \/>\n<\/div><\/div><hr\/><div class=\"aaa-form-group appointment-docx\">\n    <div class=\"control-group\">\n        <label for=\"preferred_time\">Preferred Physician<\/label>\n        <div class=\"searchHolder search-wrapper doctors-search-live \"\n            x-data=\"searchAppointmentReferral()\" x-init=\"$watch('doctors.values')\" @click.away=\"doctors.listActive = false\">\n            <input x-model=\"doctors.id\" name=\"doctor_id\" type=\"hidden\" \/>\n            <input x-model=\"doctors.search\" name=\"doctor_name\" placeholder=\"Enter a doctor name...\"\n                class=\"searchDoctors\" type=\"text\" x-on:input.debounce=\"doctors.find($event)\" \/>\n            <span class=\"searchDoctorTrigger\" x-bind:class=\"{ 'loading': doctors.loading }\"><i class=\"fal\"\n                    x-bind:class=\"{ 'fa-spinner': doctors.loading, 'fa-search': !doctors.loading }\"><\/i><\/span>\n            <ul class=\"search-items\" x-show.transition=\"doctors.listActive\" role=\"listbox\">\n                <template x-for=\"(tag, index) in doctors.values\">\n                    <li aria-role=\"button\" x-bind:data-index=\"index\" role=\"option\">\n                        <a href=\"#\" @click.prevent=\"select($event, tag)\">\n                            <div class=\"item-image\" x-show=\"tag.image\"\n                                :style=\"'background-image: url(' + tag.image + ')'\">\n                            <\/div>\n                            <span class=\"item-content\">\n                                <span class=\"item-name\" x-text=\"tag.name\"><\/span>\n                                <span class=\"item-position\" x-html=\"tag.position\"><\/span>\n                            <\/span>\n                        <\/a>\n                    <\/li>\n                <\/template>\n            <\/ul>\n            <template x-if=\"selected\">\n                <input type=\"text\" name=\"physician\" :value=\"selected.id\" class=\"hidden d-none\" \/>\n            <\/template>\n        <\/div>\n    <\/div>\n<\/div>\n<script>\n    function searchAppointmentReferral() {\n        \/\/ document.querySelector('input[name=\"physician\"]').remove();\n        var data = {\n            doctors: {\n                loading: false,\n                listActive: false,\n                search: \"\",\n                id: \"\",\n                values: [],\n                find: function (e) {\n                    var value = e.target.value;\n                    var me = this;\n                    if (value == '') {\n                        me.loading = false;\n                        me.listActive = false;\n                        return;\n                    }\n                    this.loading = true;\n                    this.listActive = false;\n                    fetch(\"https:\/\/ssmc.ae\/wp-admin\/admin-ajax.php?action=doctors&s=\" + value)\n                        .then(function (response) {\n                            return response.json()\n                        })\n                        .then(function (response) {\n                            if (value == '') {\n                                me.loading = false;\n                                me.listActive = false;\n                                return;\n                            } else if (response.data.length) {\n                                me.values = response.data;\n                            } else {\n                                me.values = [{\n                                    id: 0,\n                                    name: 'No doctors found',\n                                    position: 'Please try another query',\n                                    url: '#'\n                                }];\n                            }\n                            me.loading = false;\n                            me.listActive = true;\n                        });\n                }\n            },\n            selected: null,\n            select: function (e, doctor) {\n                e.preventDefault();\n                if (doctor) {\n                    this.selected = doctor;\n                    this.doctors.search = doctor.name;\n                    this.doctors.id = doctor.id;\n                    this.doctors.values = [];\n                }\n                else {\n                    this.selected = null;\n                    this.doctors.search = '';\n                    this.doctors.id = '';\n                }\n            }\n        };\n        return data;\n    }\n<\/script><div class=\"aaa-form-group\"><div class=\"control-group control-group-radios control-group-interpreter\" >\n    <label  for=\"interpreter\">Does the patient need an interpreter?<span class=\"required\">*<\/span><\/label>    <div class=\"checkbox-wrap radio-wrap\">\n                    <div>\n                <input type=\"radio\" type=\"radios\" name=\"interpreter\" required=\"1\" onclick=\"jQuery(this).is(&quot;:checked&quot;) &amp;&amp; jQuery(this).val() == &quot;other&quot; ? jQuery(&quot;.control-group-interpreter_other&quot;).removeClass(&quot;hidden&quot;):jQuery(&quot;.control-group-interpreter_other&quot;).addClass(&quot;hidden&quot;)\" value=\"English\" >\n                <label class=\"radio-label\">English<\/label>\n            <\/div>\n                    <div>\n                <input type=\"radio\" type=\"radios\" name=\"interpreter\" required=\"1\" onclick=\"jQuery(this).is(&quot;:checked&quot;) &amp;&amp; jQuery(this).val() == &quot;other&quot; ? jQuery(&quot;.control-group-interpreter_other&quot;).removeClass(&quot;hidden&quot;):jQuery(&quot;.control-group-interpreter_other&quot;).addClass(&quot;hidden&quot;)\" value=\"Arabic\" >\n                <label class=\"radio-label\">Arabic<\/label>\n            <\/div>\n                    <div>\n                <input type=\"radio\" type=\"radios\" name=\"interpreter\" required=\"1\" onclick=\"jQuery(this).is(&quot;:checked&quot;) &amp;&amp; jQuery(this).val() == &quot;other&quot; ? jQuery(&quot;.control-group-interpreter_other&quot;).removeClass(&quot;hidden&quot;):jQuery(&quot;.control-group-interpreter_other&quot;).addClass(&quot;hidden&quot;)\" value=\"Urdu\" >\n                <label class=\"radio-label\">Urdu<\/label>\n            <\/div>\n                    <div>\n                <input type=\"radio\" type=\"radios\" name=\"interpreter\" required=\"1\" onclick=\"jQuery(this).is(&quot;:checked&quot;) &amp;&amp; jQuery(this).val() == &quot;other&quot; ? jQuery(&quot;.control-group-interpreter_other&quot;).removeClass(&quot;hidden&quot;):jQuery(&quot;.control-group-interpreter_other&quot;).addClass(&quot;hidden&quot;)\" value=\"other\" >\n                <label class=\"radio-label\">Other<\/label>\n            <\/div>\n            <\/div>\n<\/div><div class=\"control-group control-group-text control-group-interpreter_other hidden\" style=\"min-width: 100%;align-self: flex-end;justify-self: flex-start;\">\n        <input type=\"text\" placeholder=\"Please specify...\" name=\"interpreter_other\" style=\"max-width: 200px;\" value=\"\" \/>\n<\/div><\/div><hr\/><div class=\"aaa-form-group\"><div class=\"control-group control-group-radios control-group-related_to\" >\n    <label  for=\"related_to\">What is the request related to?<span class=\"required\">*<\/span><\/label>    <div class=\"checkbox-wrap radio-wrap\">\n                    <div>\n                <input type=\"radio\" type=\"radios\" name=\"related_to\" required=\"1\" value=\"Assessment & management\" >\n                <label class=\"radio-label\">Assessment & management<\/label>\n            <\/div>\n                    <div>\n                <input type=\"radio\" type=\"radios\" name=\"related_to\" required=\"1\" value=\"Medical report\" >\n                <label class=\"radio-label\">Medical report<\/label>\n            <\/div>\n                    <div>\n                <input type=\"radio\" type=\"radios\" name=\"related_to\" 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