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Multiple submissions are disabled for this form.\",\"reviewBackText\":\"Back to Form\",\"seeAllText\":\"See All\",\"progressMiddleText\":\"of\",\"fieldError\":\"field has an error.\",\"error\":\"Error\"};\n\tJotForm.newPaymentUI = true;\n\n var jsTime = setInterval(function(){try{\n   JotForm.jsForm = true;\n\n   if (window.CardForm) { window.CardForm.jsForm = true; } \n\tJotForm.replaceTagTest = true;\n\n   JotForm.setConditions([{\"action\":[{\"id\":\"action_1611661286097\",\"visibility\":\"Hide\",\"isError\":false,\"field\":\"21\"}],\"id\":\"1611661298012\",\"index\":\"0\",\"link\":\"Any\",\"priority\":\"0\",\"terms\":[{\"id\":\"term_1611661286097\",\"field\":\"20\",\"operator\":\"equals\",\"value\":\"YES\",\"isError\":false}],\"type\":\"field\"}]);\tJotForm.clearFieldOnHide=\"disable\";\n\tJotForm.submitError=\"jumpToFirstError\";\n\n\tJotForm.init(function(){\n\t\/*INIT-START*\/\n      JotForm.alterTexts(undefined);\n      setTimeout(function() {\n          JotForm.initMultipleUploads();\n      }, 2);\n\t\n        \n        \n\t});\n\n   clearInterval(jsTime);\n }catch(e){}}, 1000);\n\n   setTimeout(function() {\nJotForm.paymentExtrasOnTheFly([null,{\"name\":\"step21\",\"qid\":\"1\",\"text\":\"Step 2\",\"type\":\"control_head\"},null,null,null,null,null,null,{\"description\":\"\",\"name\":\"rightSide8\",\"qid\":\"8\",\"subLabel\":\"\",\"text\":\"Right Side Teeth Biting\",\"type\":\"control_fileupload\"},{\"description\":\"\",\"name\":\"leftSide9\",\"qid\":\"9\",\"subLabel\":\"\",\"text\":\"Left Side Teeth Biting\",\"type\":\"control_fileupload\"},{\"description\":\"\",\"name\":\"frontTeeth\",\"qid\":\"10\",\"subLabel\":\"\",\"text\":\"Front Teeth Biting\",\"type\":\"control_fileupload\"},{\"description\":\"\",\"name\":\"upperTeeth\",\"qid\":\"11\",\"subLabel\":\"\",\"text\":\"Upper Teeth Apart\",\"type\":\"control_fileupload\"},{\"description\":\"\",\"name\":\"lowerTeeth\",\"qid\":\"12\",\"subLabel\":\"\",\"text\":\"Lower Teeth Apart\",\"type\":\"control_fileupload\"},{\"name\":\"step113\",\"qid\":\"13\",\"text\":\"Step 1\",\"type\":\"control_head\"},{\"description\":\"\",\"name\":\"name\",\"qid\":\"14\",\"text\":\"Name\",\"type\":\"control_fullname\"},null,null,{\"description\":\"\",\"name\":\"email\",\"qid\":\"17\",\"subLabel\":\"example@example.com\",\"text\":\"Email\",\"type\":\"control_email\"},null,{\"description\":\"\",\"name\":\"phoneNumber\",\"qid\":\"19\",\"subLabel\":\"\",\"text\":\"Phone Number\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"areYou\",\"qid\":\"20\",\"text\":\"Are you a patient of of our practice?\",\"type\":\"control_yesno\"},{\"description\":\"\",\"name\":\"address\",\"qid\":\"21\",\"text\":\"Address\",\"type\":\"control_address\"},null,{\"description\":\"It's best to have a friend or family member help you take them\",\"labelText\":\"Please use a well lit room or your phones flash when taking the photos\",\"name\":\"natural20light20flash20mob600fdebfa98a4031146996\",\"qid\":\"23\",\"text\":\"natural%20light%20flash%20mob.600fdebfa98a40.31146996\",\"type\":\"control_image\"},null,null,null,{\"description\":\"Please capture an image that looks as close as possible to this and upload it on the next page\",\"labelText\":\"Right Side Teeth Biting\",\"name\":\"right600ffcb3a9253436666682\",\"qid\":\"27\",\"text\":\"right.600ffcb3a92534.36666682\",\"type\":\"control_image\"},{\"description\":\"Please capture an image that looks as close as possible to this and upload it on the next page\",\"labelText\":\"Left Side Teeth Biting\",\"name\":\"left600ffe4883061446436307\",\"qid\":\"28\",\"text\":\"left.600ffe48830614.46436307\",\"type\":\"control_image\"},{\"description\":\"Please capture an image that looks as close as possible to this and upload it on the next page\",\"labelText\":\"Front Teeth Biting\",\"name\":\"front600fff1a54088188383205\",\"qid\":\"29\",\"text\":\"front.600fff1a540881.88383205\",\"type\":\"control_image\"},{\"description\":\"Please capture an image that looks as close as possible to this and upload it on the next page\",\"labelText\":\"Upper Teeth Apart\",\"name\":\"top600fff52d8e94212045737\",\"qid\":\"30\",\"text\":\"top.600fff52d8e942.12045737\",\"type\":\"control_image\"},{\"description\":\"Please capture an image that looks as close as possible to this and upload it on the next page\",\"labelText\":\"Lower Teeth Apart\",\"name\":\"bottom600fffb8725e5387550427\",\"qid\":\"31\",\"text\":\"bottom.600fffb8725e53.87550427\",\"type\":\"control_image\"},{\"description\":\"\",\"name\":\"howCan\",\"qid\":\"32\",\"text\":\"How can we help you with your smile?\",\"type\":\"control_checkbox\"}]);}, 20); \n<\/script>\n\n      <\/div><div class=\"jfForm-wrapper\" role=\"main\"><div class=\"jfForm-backgroundContainer\"><\/div><div class=\"jfForm-backgroundUnderlay\"><\/div><div class=\"jfForm-backgroundOverlay\"><\/div><div class=\"jfForm-background\"><div class=\"jfForm-background-mask\"><\/div><\/div><div class=\"jfWelcome-wrapper\" role=\"banner\"><div class=\"jfWelcome\"><div class=\"jfWelcome-imageWrapper\" id=\"cardform-welcome-icon\"><img src=\"https:\/\/www.jotform.com\/uploads\/Gladwin_James\/form_files\/TDIC_Main.604636122fe114.19974366.png\" alt=\"\" class=\"jfWelcome-image\" loading=\"lazy\"\/><\/div><h2 id=\"header_welcomePage\" class=\"jfWelcome-header form-header\" data-component=\"header\" style=\"opacity:1\"><\/h2><div id=\"subHeader_welcomePage\" class=\"jfWelcome-description form-subHeader\">Hi there, please fill out and submit this form. You&#x27;ll need to take a few pictures for us and ideally have a friend help you with them. One of our team will review them and let you know what steps to take next.\u00a0<\/div><div class=\"jfWelcome-sectionInfo\"><span class=\"jfWelcome-sectionInfo-questionCount\"><\/span><span class=\"jfWelcome-sectionInfo-text\"><\/span><\/div><div class=\"jfWelcome-buttonWrapper\"><button class=\"jfWelcome-button\" id=\"jfCard-welcome-previous\" style=\"display:none;visibility:hidden\"><\/button><\/div><div class=\"jfWelcome-buttonWrapper\"><button class=\"jfWelcome-button\" id=\"jfCard-welcome-start\" style=\"display:inline\">START<\/button><\/div><\/div><\/div><div class=\"jfForm-logo\" role=\"img\" aria-hidden=\"true\" id=\"cardform-header-icon\"><\/div><form class=\"jotform-form\" id=\"210544995001350\" name=\"form_210544995001350\" action=\"https:\/\/submit.jotform.com\/submit\/210544995001350\" method=\"post\" autoComplete=\"on\"><input type=\"hidden\" name=\"formID\" value=\"210544995001350\"\/><ul class=\"jfForm-all form-section page-section form-all\" id=\"cardAnimationWrapper\"><li class=\"form-line\" data-type=\"control_fullname\" id=\"id_14\" data-compound-hint=\"\"><div id=\"cid_14\" class=\"jfCard-wrapper\"><div class=\"jfCard\" data-type=\"control_fullname\"><div class=\"jfCard-index\"><div>1<\/div><\/div><div class=\"jfCard-question\"><div class=\"jfQuestion-fullscreen isHidden\" aria-hidden=\"true\" role=\"button\" aria-label=\"fullscreen mode\" tabindex=\"-1\"><\/div><label for=\"input_group_14\" class=\"jfQuestion-label isLeftAlign\" id=\"label_14\"><span class=\"jsQuestionLabelContainer jfQuestionLabelContainer\">Name<\/span><span class=\"jfRequiredStar\">* <span class=\"jfRequiredStar-message\">This field is required.<\/span><\/span><\/label><span class=\"jfQuestion-description\" id=\"id_14_description\"><span><\/span><\/span><div class=\"jfCard-mobileError jsMobileErrorWrapper\"><\/div><div class=\"jfQuestion-fields\" data-wrapper-react=\"true\" role=\"group\" id=\"input_group_14\"><div class=\"jfField\" data-type=\"first\"><input type=\"text\" id=\"first_14\" name=\"q14_name[first]\" class=\"form-textbox validate[required] forFullname jfInput-input hasSublabel\" autoComplete=\"given-name\" size=\"10\" value=\"\" data-component=\"first\" required=\"\" aria-required=\"true\" aria-describedby=\"id_14_description\" aria-labelledby=\"label_14 sublabel_14_first\"\/><label class=\"jfField-sublabel \" for=\"first_14\" id=\"sublabel_14_first\">First Name<\/label><\/div><div class=\"jfField\" data-type=\"last\"><input type=\"text\" id=\"last_14\" name=\"q14_name[last]\" class=\"form-textbox validate[required] forFullname jfInput-input hasSublabel\" autoComplete=\"family-name\" size=\"15\" value=\"\" data-component=\"last\" required=\"\" aria-required=\"true\" aria-describedby=\"id_14_description\" aria-labelledby=\"label_14 sublabel_14_last\"\/><label class=\"jfField-sublabel \" for=\"last_14\" id=\"sublabel_14_last\">Last Name<\/label><\/div><\/div><\/div><div class=\"jfCard-actions\"><button style=\"display:none\" type=\"button\" class=\"jfInput-button forPrev u-left\" data-component=\"button\" aria-label=\"Previous\" data-testid=\"previousButton_0\">Previous<\/button><button style=\"display:block\" type=\"button\" class=\"jfInput-button forNext u-right\" data-component=\"button\" aria-label=\"Next\" data-testid=\"nextButton_0\">Next<\/button><button style=\"display:none\" type=\"submit\" class=\"jfInput-button forSubmit form-submit-button u-right\" data-component=\"button\" aria-label=\"Submit\" data-testid=\"submitButton\">Submit<\/button><div class=\"cf\"><div class=\"jfCard-actionsNotification\" aria-live=\"polite\"><div class=\"jfPressEnter isHidden\" aria-hidden=\"true\">Press<br\/>Enter<\/div><\/div><\/div><div class=\"jfCard-disableSubmitError\"><\/div><\/div><\/div><\/div><\/li><li class=\"form-line\" data-type=\"control_email\" id=\"id_17\"><div id=\"cid_17\" class=\"jfCard-wrapper\"><div class=\"jfCard\" data-type=\"control_email\"><div class=\"jfCard-index\"><div>2<\/div><\/div><div class=\"jfCard-question\"><div class=\"jfQuestion-fullscreen isHidden\" aria-hidden=\"true\" role=\"button\" aria-label=\"fullscreen mode\" tabindex=\"-1\"><\/div><label for=\"input_17\" class=\"jfQuestion-label isLeftAlign\" id=\"label_17\"><span class=\"jsQuestionLabelContainer jfQuestionLabelContainer\">Email<\/span><span class=\"jfRequiredStar\">* <span class=\"jfRequiredStar-message\">This field is required.<\/span><\/span><\/label><span class=\"jfQuestion-description\" id=\"id_17_description\"><span><\/span><\/span><div class=\"jfCard-mobileError jsMobileErrorWrapper\"><\/div><div class=\"jfQuestion-fields questionMode\"><div class=\"jfField\" data-type=\"email\"><input type=\"email\" id=\"input_17\" name=\"q17_email\" class=\"form-textbox validate[required, Email] forEmail jfInput-input hasSublabel\" autoComplete=\"email\" size=\"30\" value=\"\" data-component=\"email\" required=\"\" aria-required=\"true\" aria-describedby=\"id_17_description\" aria-labelledby=\"label_17 sublabel_input_17\"\/><label class=\"jfField-sublabel \" for=\"input_17\" id=\"sublabel_input_17\">example@example.com<\/label><div class=\"jfCardTooltip js-tooltipContainer\"><div class=\"js-tooltipMessageContainer-info\"><\/div><div class=\"js-tooltipMessageContainer-error\"><\/div><div class=\"jfCardTooltip-close js-tooltipCloseButton\"><span class=\"iconSvg  \"><svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 326 326\"><g data-name=\"Layer 2\"><g data-name=\"Layer 1\"><path class=\"fail-outer\" d=\"M163,0C73.12,0,0,73.12,0,163S73.12,326,163,326s163-73.12,163-163S252.88,0,163,0Z\"><\/path><path class=\"fail-inner\" d=\"M227.6,98.4a14.75,14.75,0,0,0-20.86,0L163,142.14,119.26,98.4A14.75,14.75,0,1,0,98.4,119.26L142.14,163,98.4,206.74a14.75,14.75,0,1,0,20.86,20.86L163,183.86l43.74,43.74a14.75,14.75,0,1,0,20.86-20.86L183.86,163l43.74-43.74A14.75,14.75,0,0,0,227.6,98.4Z\"><\/path><\/g><\/g><\/svg><\/span><\/div><\/div><\/div><div class=\"jfEmailVerify-loading\"><span class=\"loadingDot\"><\/span><span class=\"loadingDot isD2\"><\/span><span class=\"loadingDot isD3\"><\/span><\/div><\/div><\/div><div class=\"jfCard-actions\"><button style=\"display:block\" type=\"button\" class=\"jfInput-button forPrev u-left\" data-component=\"button\" aria-label=\"Previous\" data-testid=\"previousButton_1\">Previous<\/button><button style=\"display:block\" type=\"button\" class=\"jfInput-button forNext u-right\" data-component=\"button\" aria-label=\"Next\" data-testid=\"nextButton_1\">Next<\/button><button style=\"display:none\" type=\"submit\" class=\"jfInput-button forSubmit form-submit-button u-right\" data-component=\"button\" aria-label=\"Submit\" data-testid=\"submitButton\">Submit<\/button><div class=\"cf\"><div class=\"jfCard-actionsNotification\" aria-live=\"polite\"><div class=\"jfPressEnter isHidden\" aria-hidden=\"true\">Press<br\/>Enter<\/div><\/div><\/div><div class=\"jfCard-disableSubmitError\"><\/div><\/div><\/div><\/div><\/li><li class=\"form-line\" data-type=\"control_textbox\" id=\"id_19\"><div id=\"cid_19\" class=\"jfCard-wrapper\"><div class=\"jfCard\" data-type=\"control_textbox\"><div class=\"jfCard-index\"><div>3<\/div><\/div><div class=\"jfCard-question\"><div class=\"jfQuestion-fullscreen isHidden\" aria-hidden=\"true\" role=\"button\" aria-label=\"fullscreen mode\" tabindex=\"-1\"><\/div><label for=\"input_19\" class=\"jfQuestion-label isLeftAlign\" id=\"label_19\"><span class=\"jsQuestionLabelContainer jfQuestionLabelContainer\">Phone Number<\/span><span class=\"jfRequiredStar\">* <span class=\"jfRequiredStar-message\">This field is required.<\/span><\/span><\/label><span class=\"jfQuestion-description\" id=\"id_19_description\"><span><\/span><\/span><div class=\"jfCard-mobileError jsMobileErrorWrapper\"><\/div><div class=\"jfQuestion-fields\"><div class=\"jfField\" data-type=\"textbox\"><input type=\"text\" id=\"input_19\" name=\"q19_phoneNumber\" data-type=\"input-textbox\" class=\"form-textbox validate[required, Numeric] jfInput-input\" size=\"20\" value=\"\" data-component=\"textbox\" required=\"\" aria-required=\"true\" aria-describedby=\"id_19_description\" aria-labelledby=\"label_19\"\/><label class=\"jfField-sublabel \" for=\"input_19\" aria-hidden=\"true\" tabindex=\"-1\"><\/label><\/div><\/div><\/div><div class=\"jfCard-actions\"><button style=\"display:block\" type=\"button\" class=\"jfInput-button forPrev u-left\" data-component=\"button\" aria-label=\"Previous\" data-testid=\"previousButton_2\">Previous<\/button><button style=\"display:block\" type=\"button\" class=\"jfInput-button forNext u-right\" data-component=\"button\" aria-label=\"Next\" data-testid=\"nextButton_2\">Next<\/button><button style=\"display:none\" type=\"submit\" class=\"jfInput-button forSubmit form-submit-button u-right\" data-component=\"button\" aria-label=\"Submit\" data-testid=\"submitButton\">Submit<\/button><div class=\"cf\"><div class=\"jfCard-actionsNotification\" aria-live=\"polite\"><div class=\"jfPressEnter isHidden\" aria-hidden=\"true\">Press<br\/>Enter<\/div><\/div><\/div><div class=\"jfCard-disableSubmitError\"><\/div><\/div><\/div><\/div><\/li><li class=\"form-line\" data-type=\"control_yesno\" id=\"id_20\"><div id=\"cid_20\" class=\"jfCard-wrapper\"><div class=\"jfCard\" data-type=\"control_yesno\"><div class=\"jfCard-index\"><div>4<\/div><\/div><div class=\"jfCard-question\"><div class=\"jfQuestion-fullscreen isHidden\" aria-hidden=\"true\" role=\"button\" aria-label=\"fullscreen mode\" tabindex=\"-1\"><\/div><label for=\"input_20\" class=\"jfQuestion-label isLeftAlign\" id=\"label_20\"><span class=\"jsQuestionLabelContainer jfQuestionLabelContainer\">Are you a patient of of our practice?<\/span><span class=\"jfRequiredStar\">* <span class=\"jfRequiredStar-message\">This field is required.<\/span><\/span><\/label><span class=\"jfQuestion-description\" id=\"id_20_description\"><span><\/span><\/span><div class=\"jfCard-mobileError jsMobileErrorWrapper\"><\/div><div class=\"jfQuestion-fields\" data-wrapper-react=\"true\"><div class=\"jfField\" role=\"group\" aria-labelledby=\"label_20\"><label class=\"jfYesno\" role=\"radio\" aria-checked=\"false\"><input type=\"radio\" class=\"jfYesno-input form-radio validate[required] jsToggle\" value=\"YES\" id=\"input_input_20_0\" name=\"q20_areYou\"\/><span class=\"jfYesno-label\">YES<\/span><\/label><label class=\"jfYesno\" role=\"radio\" aria-checked=\"false\"><input type=\"radio\" class=\"jfYesno-input form-radio validate[required] jsToggle\" value=\"NO\" id=\"input_input_20_1\" name=\"q20_areYou\"\/><span class=\"jfYesno-label\">NO<\/span><\/label><\/div><\/div><\/div><div class=\"jfCard-actions\"><button style=\"display:block\" type=\"button\" class=\"jfInput-button forPrev u-left\" data-component=\"button\" aria-label=\"Previous\" data-testid=\"previousButton_3\">Previous<\/button><button style=\"display:block\" type=\"button\" class=\"jfInput-button forNext u-right\" data-component=\"button\" aria-label=\"Next\" data-testid=\"nextButton_3\">Next<\/button><button style=\"display:none\" type=\"submit\" class=\"jfInput-button forSubmit form-submit-button u-right\" data-component=\"button\" aria-label=\"Submit\" data-testid=\"submitButton\">Submit<\/button><div class=\"cf\"><div class=\"jfCard-actionsNotification\" aria-live=\"polite\"><div class=\"jfPressEnter isHidden\" aria-hidden=\"true\">Press<br\/>Enter<\/div><\/div><\/div><div class=\"jfCard-disableSubmitError\"><\/div><\/div><\/div><\/div><\/li><li class=\"form-line\" data-type=\"control_address\" id=\"id_21\" data-compound-hint=\"\"><div id=\"cid_21\" class=\"jfCard-wrapper\"><div class=\"jfCard\" data-type=\"control_address\"><div class=\"jfCard-index\"><div>5<\/div><\/div><div class=\"jfCard-question\"><div class=\"jfQuestion-fullscreen isHidden\" aria-hidden=\"true\" role=\"button\" aria-label=\"fullscreen mode\" tabindex=\"-1\"><\/div><label for=\"input_group_21\" class=\"jfQuestion-label isLeftAlign\" id=\"label_21\"><span class=\"jsQuestionLabelContainer jfQuestionLabelContainer\">Address<\/span><\/label><span class=\"jfQuestion-description\" id=\"id_21_description\"><span><\/span><\/span><div class=\"jfCard-mobileError jsMobileErrorWrapper\"><\/div><div class=\" jfQuestion-fields isCompoundField form-address-table jfAddress-doubleColumn jfAddress-clean jfAddress-hasGeolocation \" data-wrapper-react=\"true\" role=\"group\" id=\"input_group_21\"><div class=\"jfField   jfAddress-search\" data-type=\"address_search\"><input type=\"text\" id=\"input_21_addr_search\" name=\"q21_address[addr_search]\" class=\"form-textbox form-address-line form-address-search forSearch jfInput-input\" data-qid=\"cid_21\" autoComplete=\"address-search\" value=\"\" placeholder=\"Enter a location\" data-component=\"address_search\" aria-required=\"false\" aria-describedby=\"id_21_description\" aria-labelledby=\"label_21\"\/><label class=\"jfField-sublabel \" for=\"input_21_addr_search\" aria-hidden=\"true\" tabindex=\"-1\"><\/label><div class=\"jfAddress-items\"><div class=\"jfAddress-clear\" tabindex=\"0\"><\/div><div class=\"jfAddress-geolocation\" id=\"input_21_addr_locate\" tabindex=\"0\"><div class=\"jfGeolocation-svg isNormalState\"><\/div><div class=\"jfGeolocation-svg isLoadingState\"><svg class=\"circularInner\" viewBox=\"25 25 50 50\"><circle class=\"circularPath\" cx=\"50\" cy=\"50\" r=\"20\" fill=\"none\" stroke-width=\"2\" stroke-miterlimit=\"10\" stroke=\"#3575BC\"><\/circle><\/svg><\/div><\/div><\/div><\/div><div class=\"jfField  \" data-type=\"address_line_1\"><input type=\"text\" id=\"input_21_addr_line1\" name=\"q21_address[addr_line1]\" class=\"form-textbox form-address-line form-address-addr1 forAddress jfInput-input hasSublabel\" autoComplete=\"address-line1\" value=\"\" data-component=\"address_line_1\" aria-required=\"false\" aria-describedby=\"id_21_description\" aria-label=\"Number &amp; Street Address\" aria-labelledby=\"label_21 sublabel_21_addr_line1\"\/><label class=\"jfField-sublabel \" for=\"input_21_addr_line1\" id=\"sublabel_21_addr_line1\">Number &amp; Street Address<\/label><\/div><div class=\"jfField  \" data-type=\"address_line_2\"><input type=\"text\" id=\"input_21_addr_line2\" name=\"q21_address[addr_line2]\" class=\"form-textbox form-address-line form-address-addr2 forAddress jfInput-input hasSublabel\" autoComplete=\"address-line2\" size=\"46\" value=\"\" data-component=\"address_line_2\" aria-required=\"false\" aria-describedby=\"id_21_description\" aria-label=\"Street Address Line 2\" aria-labelledby=\"label_21 sublabel_21_addr_line2\"\/><label class=\"jfField-sublabel \" for=\"input_21_addr_line2\" id=\"sublabel_21_addr_line2\">Street Address Line 2<\/label><\/div><div class=\"jfField  \" data-type=\"city\"><input type=\"text\" id=\"input_21_city\" name=\"q21_address[city]\" class=\"form-textbox form-address-city forAddress jfInput-input hasSublabel\" autoComplete=\"address-level2\" size=\"21\" value=\"\" data-component=\"city\" aria-required=\"false\" aria-describedby=\"id_21_description\" aria-label=\"City\" aria-labelledby=\"label_21 sublabel_21_city\"\/><label class=\"jfField-sublabel \" for=\"input_21_city\" id=\"sublabel_21_city\">City<\/label><\/div><div class=\"jfField isHidden \" data-type=\"state\" style=\"display:none\"><input type=\"text\" id=\"input_21_state\" name=\"q21_address[state]\" class=\"form-textbox form-address-state forAddress jfInput-input hasSublabel\" autoComplete=\"new-password\" size=\"22\" value=\"\" data-component=\"state\" aria-required=\"false\" aria-describedby=\"id_21_description\" aria-labelledby=\"label_21 sublabel_21_state\"\/><label class=\"jfField-sublabel \" for=\"input_21_state\" id=\"sublabel_21_state\">County<\/label><\/div><div class=\"jfField  \" data-type=\"zip\"><input type=\"text\" id=\"input_21_postal\" name=\"q21_address[postal]\" class=\"form-textbox form-address-postal forAddress jfInput-input hasSublabel\" autoComplete=\"postal-code\" size=\"10\" value=\"\" data-component=\"zip\" aria-required=\"false\" aria-describedby=\"id_21_description\" aria-label=\"Post Code\" aria-labelledby=\"label_21 sublabel_21_postal\"\/><label class=\"jfField-sublabel \" for=\"input_21_postal\" id=\"sublabel_21_postal\">Post Code<\/label><\/div><div class=\"jfField isFilled isHidden \" data-type=\"country\" style=\"display:none\" aria-hidden=\"true\"><select data-component=\"country\" tabindex=\"-1\" id=\"input_21_country\" name=\"q21_address[country]\" class=\"form-dropdown form-address-country\" autoComplete=\"new-password\" aria-labelledby=\"label_21 sublabel_21_country\"><option value=\"\">Please Select<\/option><option value=\"United States\">United States<\/option><option value=\"Afghanistan\">Afghanistan<\/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=\"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=\"The Bahamas\">The 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=\"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=\"Christmas Island\">Christmas Island<\/option><option value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option value=\"Colombia\">Colombia<\/option><option value=\"Comoros\">Comoros<\/option><option value=\"Congo\">Congo<\/option><option value=\"Cook Islands\">Cook Islands<\/option><option value=\"Costa Rica\">Costa Rica<\/option><option value=\"Cote d&#x27;Ivoire\">Cote d&#x27;Ivoire<\/option><option value=\"Croatia\">Croatia<\/option><option value=\"Cuba\">Cuba<\/option><option value=\"Cura\u00e7ao\">Cura\u00e7ao<\/option><option value=\"Cyprus\">Cyprus<\/option><option value=\"Czech Republic\">Czech Republic<\/option><option value=\"Democratic Republic of the Congo\">Democratic Republic of the Congo<\/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=\"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=\"Falkland Islands\">Falkland Islands<\/option><option value=\"Faroe Islands\">Faroe Islands<\/option><option value=\"Fiji\">Fiji<\/option><option value=\"Finland\">Finland<\/option><option value=\"France\">France<\/option><option value=\"French Polynesia\">French Polynesia<\/option><option value=\"Gabon\">Gabon<\/option><option value=\"The Gambia\">The 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=\"Macau\">Macau<\/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=\"Nagorno-Karabakh\">Nagorno-Karabakh<\/option><option value=\"Namibia\">Namibia<\/option><option value=\"Nauru\">Nauru<\/option><option value=\"Nepal\">Nepal<\/option><option value=\"Netherlands\">Netherlands<\/option><option value=\"Netherlands Antilles\">Netherlands Antilles<\/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=\"Niue\">Niue<\/option><option value=\"Norfolk Island\">Norfolk Island<\/option><option value=\"Turkish Republic of Northern Cyprus\">Turkish Republic of Northern Cyprus<\/option><option value=\"Northern Mariana\">Northern Mariana<\/option><option value=\"Norway\">Norway<\/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 Islands\">Pitcairn Islands<\/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=\"Republic of the Congo\">Republic of the Congo<\/option><option value=\"Romania\">Romania<\/option><option value=\"Russia\">Russia<\/option><option value=\"Rwanda\">Rwanda<\/option><option value=\"Saint Barthelemy\">Saint Barthelemy<\/option><option value=\"Saint Helena\">Saint Helena<\/option><option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\">Saint Lucia<\/option><option value=\"Saint Martin\">Saint Martin<\/option><option value=\"Saint Pierre and Miquelon\">Saint Pierre and Miquelon<\/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\">Serbia<\/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=\"Somaliland\">Somaliland<\/option><option value=\"South Africa\">South Africa<\/option><option value=\"South Ossetia\">South Ossetia<\/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=\"Svalbard\">Svalbard<\/option><option value=\"eSwatini\">eSwatini<\/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=\"Timor-Leste\">Timor-Leste<\/option><option value=\"Togo\">Togo<\/option><option value=\"Tokelau\">Tokelau<\/option><option value=\"Tonga\">Tonga<\/option><option value=\"Transnistria Pridnestrovie\">Transnistria Pridnestrovie<\/option><option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option value=\"Tristan da Cunha\">Tristan da Cunha<\/option><option value=\"Tunisia\">Tunisia<\/option><option value=\"Turkey\">Turkey<\/option><option value=\"Turkmenistan\">Turkmenistan<\/option><option value=\"Turks and Caicos Islands\">Turks and Caicos Islands<\/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=\"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=\"British Virgin Islands\">British Virgin Islands<\/option><option value=\"Isle of Man\">Isle of Man<\/option><option value=\"US Virgin Islands\">US Virgin Islands<\/option><option value=\"Wallis and Futuna\">Wallis and Futuna<\/option><option value=\"Western Sahara\">Western Sahara<\/option><option value=\"Yemen\">Yemen<\/option><option value=\"Zambia\">Zambia<\/option><option value=\"Zimbabwe\">Zimbabwe<\/option><option value=\"other\">Other<\/option><\/select><div class=\"jfInput-dropdown hasSearch isDrawer\" datatype=\"multiselect\" role=\"presentation\"><div class=\"jfDropdown-wrapper\" tabindex=\"0\" aria-haspopup=\"true\" aria-labelledby=\"label_21 sublabel_21_country jfDropdown-chip-input_21_country\"><div class=\"jfDropdown-chipContainer\"><span class=\"jfDropdown-chip isSingle\" id=\"jfDropdown-chip-input_21_country\" style=\"display:none\">Please Select<\/span><div class=\"jfDropdown-searchWrapper\"><input type=\"text\" class=\"form-textbox jfDropdown-search\" name=\"dropdown_search\" autoComplete=\"off\" placeholder=\"Please Select\" aria-label=\"Please Select\" value=\"Please Select\"\/><\/div><\/div><span class=\"jfDropdown-toggle\"><\/span><\/div><div id=\"jfDropdown-optionList-21-country\" class=\"jfDropdown-optionListWrapper forDrawer\"><ul data-component=\"country\" aria-labelledby=\"label_21 sublabel_21_country\" role=\"listbox\" class=\"jfDropdown-optionList form-dropdown\"><li role=\"option\" data-value=\"\" class=\"jfDropdown-optionListItem\">Please Select<\/li><li role=\"option\" data-value=\"United States\" class=\"jfDropdown-optionListItem\">United States<\/li><li role=\"option\" data-value=\"Afghanistan\" class=\"jfDropdown-optionListItem\">Afghanistan<\/li><li role=\"option\" data-value=\"Albania\" class=\"jfDropdown-optionListItem\">Albania<\/li><li role=\"option\" data-value=\"Algeria\" class=\"jfDropdown-optionListItem\">Algeria<\/li><li role=\"option\" data-value=\"American Samoa\" class=\"jfDropdown-optionListItem\">American Samoa<\/li><li role=\"option\" data-value=\"Andorra\" class=\"jfDropdown-optionListItem\">Andorra<\/li><li role=\"option\" data-value=\"Angola\" class=\"jfDropdown-optionListItem\">Angola<\/li><li role=\"option\" data-value=\"Anguilla\" class=\"jfDropdown-optionListItem\">Anguilla<\/li><li role=\"option\" data-value=\"Antigua and Barbuda\" class=\"jfDropdown-optionListItem\">Antigua and Barbuda<\/li><li role=\"option\" data-value=\"Argentina\" class=\"jfDropdown-optionListItem\">Argentina<\/li><li role=\"option\" data-value=\"Armenia\" class=\"jfDropdown-optionListItem\">Armenia<\/li><li role=\"option\" data-value=\"Aruba\" class=\"jfDropdown-optionListItem\">Aruba<\/li><li role=\"option\" data-value=\"Australia\" class=\"jfDropdown-optionListItem\">Australia<\/li><li role=\"option\" data-value=\"Austria\" class=\"jfDropdown-optionListItem\">Austria<\/li><li role=\"option\" data-value=\"Azerbaijan\" class=\"jfDropdown-optionListItem\">Azerbaijan<\/li><li role=\"option\" data-value=\"The Bahamas\" class=\"jfDropdown-optionListItem\">The Bahamas<\/li><li role=\"option\" data-value=\"Bahrain\" class=\"jfDropdown-optionListItem\">Bahrain<\/li><li role=\"option\" data-value=\"Bangladesh\" class=\"jfDropdown-optionListItem\">Bangladesh<\/li><li role=\"option\" data-value=\"Barbados\" class=\"jfDropdown-optionListItem\">Barbados<\/li><li role=\"option\" data-value=\"Belarus\" class=\"jfDropdown-optionListItem\">Belarus<\/li><li role=\"option\" data-value=\"Belgium\" class=\"jfDropdown-optionListItem\">Belgium<\/li><li role=\"option\" data-value=\"Belize\" class=\"jfDropdown-optionListItem\">Belize<\/li><li role=\"option\" data-value=\"Benin\" class=\"jfDropdown-optionListItem\">Benin<\/li><li role=\"option\" data-value=\"Bermuda\" class=\"jfDropdown-optionListItem\">Bermuda<\/li><li role=\"option\" data-value=\"Bhutan\" class=\"jfDropdown-optionListItem\">Bhutan<\/li><li role=\"option\" data-value=\"Bolivia\" class=\"jfDropdown-optionListItem\">Bolivia<\/li><li role=\"option\" data-value=\"Bosnia and Herzegovina\" class=\"jfDropdown-optionListItem\">Bosnia and Herzegovina<\/li><li role=\"option\" data-value=\"Botswana\" class=\"jfDropdown-optionListItem\">Botswana<\/li><li role=\"option\" data-value=\"Brazil\" class=\"jfDropdown-optionListItem\">Brazil<\/li><li role=\"option\" data-value=\"Brunei\" class=\"jfDropdown-optionListItem\">Brunei<\/li><li role=\"option\" data-value=\"Bulgaria\" class=\"jfDropdown-optionListItem\">Bulgaria<\/li><li role=\"option\" data-value=\"Burkina Faso\" class=\"jfDropdown-optionListItem\">Burkina Faso<\/li><li role=\"option\" data-value=\"Burundi\" class=\"jfDropdown-optionListItem\">Burundi<\/li><li role=\"option\" data-value=\"Cambodia\" class=\"jfDropdown-optionListItem\">Cambodia<\/li><li role=\"option\" data-value=\"Cameroon\" class=\"jfDropdown-optionListItem\">Cameroon<\/li><li role=\"option\" data-value=\"Canada\" class=\"jfDropdown-optionListItem\">Canada<\/li><li role=\"option\" data-value=\"Cape Verde\" class=\"jfDropdown-optionListItem\">Cape Verde<\/li><li role=\"option\" data-value=\"Cayman Islands\" class=\"jfDropdown-optionListItem\">Cayman Islands<\/li><li role=\"option\" data-value=\"Central African Republic\" class=\"jfDropdown-optionListItem\">Central African Republic<\/li><li role=\"option\" data-value=\"Chad\" class=\"jfDropdown-optionListItem\">Chad<\/li><li role=\"option\" data-value=\"Chile\" class=\"jfDropdown-optionListItem\">Chile<\/li><li role=\"option\" data-value=\"China\" class=\"jfDropdown-optionListItem\">China<\/li><li role=\"option\" data-value=\"Christmas Island\" class=\"jfDropdown-optionListItem\">Christmas Island<\/li><li role=\"option\" data-value=\"Cocos (Keeling) Islands\" class=\"jfDropdown-optionListItem\">Cocos (Keeling) Islands<\/li><li role=\"option\" data-value=\"Colombia\" class=\"jfDropdown-optionListItem\">Colombia<\/li><li role=\"option\" data-value=\"Comoros\" class=\"jfDropdown-optionListItem\">Comoros<\/li><li role=\"option\" data-value=\"Congo\" class=\"jfDropdown-optionListItem\">Congo<\/li><li role=\"option\" data-value=\"Cook Islands\" class=\"jfDropdown-optionListItem\">Cook Islands<\/li><li role=\"option\" data-value=\"Costa Rica\" class=\"jfDropdown-optionListItem\">Costa Rica<\/li><li role=\"option\" data-value=\"Cote d&#x27;Ivoire\" class=\"jfDropdown-optionListItem\">Cote d&#x27;Ivoire<\/li><li role=\"option\" data-value=\"Croatia\" class=\"jfDropdown-optionListItem\">Croatia<\/li><li role=\"option\" data-value=\"Cuba\" class=\"jfDropdown-optionListItem\">Cuba<\/li><li role=\"option\" data-value=\"Cura\u00e7ao\" class=\"jfDropdown-optionListItem\">Cura\u00e7ao<\/li><li role=\"option\" data-value=\"Cyprus\" class=\"jfDropdown-optionListItem\">Cyprus<\/li><li role=\"option\" data-value=\"Czech Republic\" class=\"jfDropdown-optionListItem\">Czech Republic<\/li><li role=\"option\" data-value=\"Democratic Republic of the Congo\" class=\"jfDropdown-optionListItem\">Democratic Republic of the Congo<\/li><li role=\"option\" data-value=\"Denmark\" class=\"jfDropdown-optionListItem\">Denmark<\/li><li role=\"option\" data-value=\"Djibouti\" class=\"jfDropdown-optionListItem\">Djibouti<\/li><li role=\"option\" data-value=\"Dominica\" class=\"jfDropdown-optionListItem\">Dominica<\/li><li role=\"option\" data-value=\"Dominican Republic\" class=\"jfDropdown-optionListItem\">Dominican Republic<\/li><li role=\"option\" data-value=\"Ecuador\" class=\"jfDropdown-optionListItem\">Ecuador<\/li><li role=\"option\" data-value=\"Egypt\" class=\"jfDropdown-optionListItem\">Egypt<\/li><li role=\"option\" data-value=\"El Salvador\" class=\"jfDropdown-optionListItem\">El Salvador<\/li><li role=\"option\" data-value=\"Equatorial Guinea\" class=\"jfDropdown-optionListItem\">Equatorial Guinea<\/li><li role=\"option\" data-value=\"Eritrea\" class=\"jfDropdown-optionListItem\">Eritrea<\/li><li role=\"option\" data-value=\"Estonia\" class=\"jfDropdown-optionListItem\">Estonia<\/li><li role=\"option\" data-value=\"Ethiopia\" class=\"jfDropdown-optionListItem\">Ethiopia<\/li><li role=\"option\" data-value=\"Falkland Islands\" class=\"jfDropdown-optionListItem\">Falkland Islands<\/li><li role=\"option\" data-value=\"Faroe Islands\" class=\"jfDropdown-optionListItem\">Faroe Islands<\/li><li role=\"option\" data-value=\"Fiji\" class=\"jfDropdown-optionListItem\">Fiji<\/li><li role=\"option\" data-value=\"Finland\" class=\"jfDropdown-optionListItem\">Finland<\/li><li role=\"option\" data-value=\"France\" class=\"jfDropdown-optionListItem\">France<\/li><li role=\"option\" data-value=\"French Polynesia\" class=\"jfDropdown-optionListItem\">French Polynesia<\/li><li role=\"option\" data-value=\"Gabon\" class=\"jfDropdown-optionListItem\">Gabon<\/li><li role=\"option\" data-value=\"The Gambia\" class=\"jfDropdown-optionListItem\">The Gambia<\/li><li role=\"option\" data-value=\"Georgia\" class=\"jfDropdown-optionListItem\">Georgia<\/li><li role=\"option\" data-value=\"Germany\" class=\"jfDropdown-optionListItem\">Germany<\/li><li role=\"option\" data-value=\"Ghana\" class=\"jfDropdown-optionListItem\">Ghana<\/li><li role=\"option\" data-value=\"Gibraltar\" class=\"jfDropdown-optionListItem\">Gibraltar<\/li><li role=\"option\" data-value=\"Greece\" class=\"jfDropdown-optionListItem\">Greece<\/li><li role=\"option\" data-value=\"Greenland\" class=\"jfDropdown-optionListItem\">Greenland<\/li><li role=\"option\" data-value=\"Grenada\" class=\"jfDropdown-optionListItem\">Grenada<\/li><li role=\"option\" data-value=\"Guadeloupe\" class=\"jfDropdown-optionListItem\">Guadeloupe<\/li><li role=\"option\" data-value=\"Guam\" class=\"jfDropdown-optionListItem\">Guam<\/li><li role=\"option\" data-value=\"Guatemala\" class=\"jfDropdown-optionListItem\">Guatemala<\/li><li role=\"option\" data-value=\"Guernsey\" class=\"jfDropdown-optionListItem\">Guernsey<\/li><li role=\"option\" data-value=\"Guinea\" class=\"jfDropdown-optionListItem\">Guinea<\/li><li role=\"option\" data-value=\"Guinea-Bissau\" class=\"jfDropdown-optionListItem\">Guinea-Bissau<\/li><li role=\"option\" data-value=\"Guyana\" class=\"jfDropdown-optionListItem\">Guyana<\/li><li role=\"option\" data-value=\"Haiti\" class=\"jfDropdown-optionListItem\">Haiti<\/li><li role=\"option\" data-value=\"Honduras\" class=\"jfDropdown-optionListItem\">Honduras<\/li><li role=\"option\" data-value=\"Hong Kong\" class=\"jfDropdown-optionListItem\">Hong Kong<\/li><li role=\"option\" data-value=\"Hungary\" class=\"jfDropdown-optionListItem\">Hungary<\/li><li role=\"option\" data-value=\"Iceland\" class=\"jfDropdown-optionListItem\">Iceland<\/li><li role=\"option\" data-value=\"India\" class=\"jfDropdown-optionListItem\">India<\/li><li role=\"option\" data-value=\"Indonesia\" class=\"jfDropdown-optionListItem\">Indonesia<\/li><li role=\"option\" data-value=\"Iran\" class=\"jfDropdown-optionListItem\">Iran<\/li><li role=\"option\" data-value=\"Iraq\" class=\"jfDropdown-optionListItem\">Iraq<\/li><li role=\"option\" data-value=\"Ireland\" class=\"jfDropdown-optionListItem\">Ireland<\/li><li role=\"option\" data-value=\"Israel\" class=\"jfDropdown-optionListItem\">Israel<\/li><li role=\"option\" data-value=\"Italy\" class=\"jfDropdown-optionListItem\">Italy<\/li><li role=\"option\" data-value=\"Jamaica\" class=\"jfDropdown-optionListItem\">Jamaica<\/li><li role=\"option\" data-value=\"Japan\" class=\"jfDropdown-optionListItem\">Japan<\/li><li role=\"option\" data-value=\"Jersey\" class=\"jfDropdown-optionListItem\">Jersey<\/li><li role=\"option\" data-value=\"Jordan\" class=\"jfDropdown-optionListItem\">Jordan<\/li><li role=\"option\" data-value=\"Kazakhstan\" class=\"jfDropdown-optionListItem\">Kazakhstan<\/li><li role=\"option\" data-value=\"Kenya\" class=\"jfDropdown-optionListItem\">Kenya<\/li><li role=\"option\" data-value=\"Kiribati\" class=\"jfDropdown-optionListItem\">Kiribati<\/li><li role=\"option\" data-value=\"North Korea\" class=\"jfDropdown-optionListItem\">North Korea<\/li><li role=\"option\" data-value=\"South Korea\" class=\"jfDropdown-optionListItem\">South Korea<\/li><li role=\"option\" data-value=\"Kosovo\" class=\"jfDropdown-optionListItem\">Kosovo<\/li><li role=\"option\" data-value=\"Kuwait\" class=\"jfDropdown-optionListItem\">Kuwait<\/li><li role=\"option\" data-value=\"Kyrgyzstan\" class=\"jfDropdown-optionListItem\">Kyrgyzstan<\/li><li role=\"option\" data-value=\"Laos\" class=\"jfDropdown-optionListItem\">Laos<\/li><li role=\"option\" data-value=\"Latvia\" class=\"jfDropdown-optionListItem\">Latvia<\/li><li role=\"option\" data-value=\"Lebanon\" class=\"jfDropdown-optionListItem\">Lebanon<\/li><li role=\"option\" data-value=\"Lesotho\" class=\"jfDropdown-optionListItem\">Lesotho<\/li><li role=\"option\" data-value=\"Liberia\" class=\"jfDropdown-optionListItem\">Liberia<\/li><li role=\"option\" data-value=\"Libya\" class=\"jfDropdown-optionListItem\">Libya<\/li><li role=\"option\" data-value=\"Liechtenstein\" class=\"jfDropdown-optionListItem\">Liechtenstein<\/li><li role=\"option\" data-value=\"Lithuania\" class=\"jfDropdown-optionListItem\">Lithuania<\/li><li role=\"option\" data-value=\"Luxembourg\" class=\"jfDropdown-optionListItem\">Luxembourg<\/li><li role=\"option\" data-value=\"Macau\" class=\"jfDropdown-optionListItem\">Macau<\/li><li role=\"option\" data-value=\"Macedonia\" class=\"jfDropdown-optionListItem\">Macedonia<\/li><li role=\"option\" data-value=\"Madagascar\" class=\"jfDropdown-optionListItem\">Madagascar<\/li><li role=\"option\" data-value=\"Malawi\" class=\"jfDropdown-optionListItem\">Malawi<\/li><li role=\"option\" data-value=\"Malaysia\" class=\"jfDropdown-optionListItem\">Malaysia<\/li><li role=\"option\" data-value=\"Maldives\" class=\"jfDropdown-optionListItem\">Maldives<\/li><li role=\"option\" data-value=\"Mali\" class=\"jfDropdown-optionListItem\">Mali<\/li><li role=\"option\" data-value=\"Malta\" class=\"jfDropdown-optionListItem\">Malta<\/li><li role=\"option\" data-value=\"Marshall Islands\" class=\"jfDropdown-optionListItem\">Marshall Islands<\/li><li role=\"option\" data-value=\"Martinique\" class=\"jfDropdown-optionListItem\">Martinique<\/li><li role=\"option\" data-value=\"Mauritania\" class=\"jfDropdown-optionListItem\">Mauritania<\/li><li role=\"option\" data-value=\"Mauritius\" class=\"jfDropdown-optionListItem\">Mauritius<\/li><li role=\"option\" data-value=\"Mayotte\" class=\"jfDropdown-optionListItem\">Mayotte<\/li><li role=\"option\" data-value=\"Mexico\" class=\"jfDropdown-optionListItem\">Mexico<\/li><li role=\"option\" data-value=\"Micronesia\" class=\"jfDropdown-optionListItem\">Micronesia<\/li><li role=\"option\" data-value=\"Moldova\" class=\"jfDropdown-optionListItem\">Moldova<\/li><li role=\"option\" data-value=\"Monaco\" class=\"jfDropdown-optionListItem\">Monaco<\/li><li role=\"option\" data-value=\"Mongolia\" class=\"jfDropdown-optionListItem\">Mongolia<\/li><li role=\"option\" data-value=\"Montenegro\" class=\"jfDropdown-optionListItem\">Montenegro<\/li><li role=\"option\" data-value=\"Montserrat\" class=\"jfDropdown-optionListItem\">Montserrat<\/li><li role=\"option\" data-value=\"Morocco\" class=\"jfDropdown-optionListItem\">Morocco<\/li><li role=\"option\" data-value=\"Mozambique\" class=\"jfDropdown-optionListItem\">Mozambique<\/li><li role=\"option\" data-value=\"Myanmar\" class=\"jfDropdown-optionListItem\">Myanmar<\/li><li role=\"option\" data-value=\"Nagorno-Karabakh\" class=\"jfDropdown-optionListItem\">Nagorno-Karabakh<\/li><li role=\"option\" data-value=\"Namibia\" class=\"jfDropdown-optionListItem\">Namibia<\/li><li role=\"option\" data-value=\"Nauru\" class=\"jfDropdown-optionListItem\">Nauru<\/li><li role=\"option\" data-value=\"Nepal\" class=\"jfDropdown-optionListItem\">Nepal<\/li><li role=\"option\" data-value=\"Netherlands\" class=\"jfDropdown-optionListItem\">Netherlands<\/li><li role=\"option\" data-value=\"Netherlands Antilles\" class=\"jfDropdown-optionListItem\">Netherlands Antilles<\/li><li role=\"option\" data-value=\"New Caledonia\" class=\"jfDropdown-optionListItem\">New Caledonia<\/li><li role=\"option\" data-value=\"New Zealand\" class=\"jfDropdown-optionListItem\">New Zealand<\/li><li role=\"option\" data-value=\"Nicaragua\" class=\"jfDropdown-optionListItem\">Nicaragua<\/li><li role=\"option\" data-value=\"Niger\" class=\"jfDropdown-optionListItem\">Niger<\/li><li role=\"option\" data-value=\"Nigeria\" class=\"jfDropdown-optionListItem\">Nigeria<\/li><li role=\"option\" data-value=\"Niue\" class=\"jfDropdown-optionListItem\">Niue<\/li><li role=\"option\" data-value=\"Norfolk Island\" class=\"jfDropdown-optionListItem\">Norfolk Island<\/li><li role=\"option\" data-value=\"Turkish Republic of Northern Cyprus\" class=\"jfDropdown-optionListItem\">Turkish Republic of Northern Cyprus<\/li><li role=\"option\" data-value=\"Northern Mariana\" class=\"jfDropdown-optionListItem\">Northern Mariana<\/li><li role=\"option\" data-value=\"Norway\" class=\"jfDropdown-optionListItem\">Norway<\/li><li role=\"option\" data-value=\"Oman\" class=\"jfDropdown-optionListItem\">Oman<\/li><li role=\"option\" data-value=\"Pakistan\" class=\"jfDropdown-optionListItem\">Pakistan<\/li><li role=\"option\" data-value=\"Palau\" class=\"jfDropdown-optionListItem\">Palau<\/li><li role=\"option\" data-value=\"Palestine\" class=\"jfDropdown-optionListItem\">Palestine<\/li><li role=\"option\" data-value=\"Panama\" class=\"jfDropdown-optionListItem\">Panama<\/li><li role=\"option\" data-value=\"Papua New Guinea\" class=\"jfDropdown-optionListItem\">Papua New Guinea<\/li><li role=\"option\" data-value=\"Paraguay\" class=\"jfDropdown-optionListItem\">Paraguay<\/li><li role=\"option\" data-value=\"Peru\" class=\"jfDropdown-optionListItem\">Peru<\/li><li role=\"option\" data-value=\"Philippines\" class=\"jfDropdown-optionListItem\">Philippines<\/li><li role=\"option\" data-value=\"Pitcairn Islands\" class=\"jfDropdown-optionListItem\">Pitcairn Islands<\/li><li role=\"option\" data-value=\"Poland\" class=\"jfDropdown-optionListItem\">Poland<\/li><li role=\"option\" data-value=\"Portugal\" class=\"jfDropdown-optionListItem\">Portugal<\/li><li role=\"option\" data-value=\"Puerto Rico\" class=\"jfDropdown-optionListItem\">Puerto Rico<\/li><li role=\"option\" data-value=\"Qatar\" class=\"jfDropdown-optionListItem\">Qatar<\/li><li role=\"option\" data-value=\"Republic of the Congo\" class=\"jfDropdown-optionListItem\">Republic of the Congo<\/li><li role=\"option\" data-value=\"Romania\" class=\"jfDropdown-optionListItem\">Romania<\/li><li role=\"option\" data-value=\"Russia\" class=\"jfDropdown-optionListItem\">Russia<\/li><li role=\"option\" data-value=\"Rwanda\" class=\"jfDropdown-optionListItem\">Rwanda<\/li><li role=\"option\" data-value=\"Saint Barthelemy\" class=\"jfDropdown-optionListItem\">Saint Barthelemy<\/li><li role=\"option\" data-value=\"Saint Helena\" class=\"jfDropdown-optionListItem\">Saint Helena<\/li><li role=\"option\" data-value=\"Saint Kitts and Nevis\" class=\"jfDropdown-optionListItem\">Saint Kitts and Nevis<\/li><li role=\"option\" data-value=\"Saint Lucia\" class=\"jfDropdown-optionListItem\">Saint Lucia<\/li><li role=\"option\" data-value=\"Saint Martin\" class=\"jfDropdown-optionListItem\">Saint Martin<\/li><li role=\"option\" data-value=\"Saint Pierre and Miquelon\" class=\"jfDropdown-optionListItem\">Saint Pierre and Miquelon<\/li><li role=\"option\" data-value=\"Saint Vincent and the Grenadines\" class=\"jfDropdown-optionListItem\">Saint Vincent and the Grenadines<\/li><li role=\"option\" data-value=\"Samoa\" class=\"jfDropdown-optionListItem\">Samoa<\/li><li role=\"option\" data-value=\"San Marino\" class=\"jfDropdown-optionListItem\">San Marino<\/li><li role=\"option\" data-value=\"Sao Tome and Principe\" class=\"jfDropdown-optionListItem\">Sao Tome and Principe<\/li><li role=\"option\" data-value=\"Saudi Arabia\" class=\"jfDropdown-optionListItem\">Saudi Arabia<\/li><li role=\"option\" data-value=\"Senegal\" class=\"jfDropdown-optionListItem\">Senegal<\/li><li role=\"option\" data-value=\"Serbia\" class=\"jfDropdown-optionListItem\">Serbia<\/li><li role=\"option\" data-value=\"Seychelles\" class=\"jfDropdown-optionListItem\">Seychelles<\/li><li role=\"option\" data-value=\"Sierra Leone\" class=\"jfDropdown-optionListItem\">Sierra Leone<\/li><li role=\"option\" data-value=\"Singapore\" class=\"jfDropdown-optionListItem\">Singapore<\/li><li role=\"option\" data-value=\"Slovakia\" class=\"jfDropdown-optionListItem\">Slovakia<\/li><li role=\"option\" data-value=\"Slovenia\" class=\"jfDropdown-optionListItem\">Slovenia<\/li><li role=\"option\" data-value=\"Solomon Islands\" class=\"jfDropdown-optionListItem\">Solomon Islands<\/li><li role=\"option\" data-value=\"Somalia\" class=\"jfDropdown-optionListItem\">Somalia<\/li><li role=\"option\" data-value=\"Somaliland\" class=\"jfDropdown-optionListItem\">Somaliland<\/li><li role=\"option\" data-value=\"South Africa\" class=\"jfDropdown-optionListItem\">South Africa<\/li><li role=\"option\" data-value=\"South Ossetia\" class=\"jfDropdown-optionListItem\">South Ossetia<\/li><li role=\"option\" data-value=\"South Sudan\" class=\"jfDropdown-optionListItem\">South Sudan<\/li><li role=\"option\" data-value=\"Spain\" class=\"jfDropdown-optionListItem\">Spain<\/li><li role=\"option\" data-value=\"Sri Lanka\" class=\"jfDropdown-optionListItem\">Sri Lanka<\/li><li role=\"option\" data-value=\"Sudan\" class=\"jfDropdown-optionListItem\">Sudan<\/li><li role=\"option\" data-value=\"Suriname\" class=\"jfDropdown-optionListItem\">Suriname<\/li><li role=\"option\" data-value=\"Svalbard\" class=\"jfDropdown-optionListItem\">Svalbard<\/li><li role=\"option\" data-value=\"eSwatini\" class=\"jfDropdown-optionListItem\">eSwatini<\/li><li role=\"option\" data-value=\"Sweden\" class=\"jfDropdown-optionListItem\">Sweden<\/li><li role=\"option\" data-value=\"Switzerland\" class=\"jfDropdown-optionListItem\">Switzerland<\/li><li role=\"option\" data-value=\"Syria\" class=\"jfDropdown-optionListItem\">Syria<\/li><li role=\"option\" data-value=\"Taiwan\" class=\"jfDropdown-optionListItem\">Taiwan<\/li><li role=\"option\" data-value=\"Tajikistan\" class=\"jfDropdown-optionListItem\">Tajikistan<\/li><li role=\"option\" data-value=\"Tanzania\" class=\"jfDropdown-optionListItem\">Tanzania<\/li><li role=\"option\" data-value=\"Thailand\" class=\"jfDropdown-optionListItem\">Thailand<\/li><li role=\"option\" data-value=\"Timor-Leste\" class=\"jfDropdown-optionListItem\">Timor-Leste<\/li><li role=\"option\" data-value=\"Togo\" class=\"jfDropdown-optionListItem\">Togo<\/li><li role=\"option\" data-value=\"Tokelau\" class=\"jfDropdown-optionListItem\">Tokelau<\/li><li role=\"option\" data-value=\"Tonga\" class=\"jfDropdown-optionListItem\">Tonga<\/li><li role=\"option\" data-value=\"Transnistria Pridnestrovie\" class=\"jfDropdown-optionListItem\">Transnistria Pridnestrovie<\/li><li role=\"option\" data-value=\"Trinidad and Tobago\" class=\"jfDropdown-optionListItem\">Trinidad and Tobago<\/li><li role=\"option\" data-value=\"Tristan da Cunha\" class=\"jfDropdown-optionListItem\">Tristan da Cunha<\/li><li role=\"option\" data-value=\"Tunisia\" class=\"jfDropdown-optionListItem\">Tunisia<\/li><li role=\"option\" data-value=\"Turkey\" class=\"jfDropdown-optionListItem\">Turkey<\/li><li role=\"option\" data-value=\"Turkmenistan\" class=\"jfDropdown-optionListItem\">Turkmenistan<\/li><li role=\"option\" data-value=\"Turks and Caicos Islands\" class=\"jfDropdown-optionListItem\">Turks and Caicos Islands<\/li><li role=\"option\" data-value=\"Tuvalu\" class=\"jfDropdown-optionListItem\">Tuvalu<\/li><li role=\"option\" data-value=\"Uganda\" class=\"jfDropdown-optionListItem\">Uganda<\/li><li role=\"option\" data-value=\"Ukraine\" class=\"jfDropdown-optionListItem\">Ukraine<\/li><li role=\"option\" data-value=\"United Arab Emirates\" class=\"jfDropdown-optionListItem\">United Arab Emirates<\/li><li role=\"option\" data-value=\"United Kingdom\" class=\"jfDropdown-optionListItem\">United Kingdom<\/li><li role=\"option\" data-value=\"Uruguay\" class=\"jfDropdown-optionListItem\">Uruguay<\/li><li role=\"option\" data-value=\"Uzbekistan\" class=\"jfDropdown-optionListItem\">Uzbekistan<\/li><li role=\"option\" data-value=\"Vanuatu\" class=\"jfDropdown-optionListItem\">Vanuatu<\/li><li role=\"option\" data-value=\"Vatican City\" class=\"jfDropdown-optionListItem\">Vatican City<\/li><li role=\"option\" data-value=\"Venezuela\" class=\"jfDropdown-optionListItem\">Venezuela<\/li><li role=\"option\" data-value=\"Vietnam\" class=\"jfDropdown-optionListItem\">Vietnam<\/li><li role=\"option\" data-value=\"British Virgin Islands\" class=\"jfDropdown-optionListItem\">British Virgin Islands<\/li><li role=\"option\" data-value=\"Isle of Man\" class=\"jfDropdown-optionListItem\">Isle of Man<\/li><li role=\"option\" data-value=\"US Virgin Islands\" class=\"jfDropdown-optionListItem\">US Virgin Islands<\/li><li role=\"option\" data-value=\"Wallis and Futuna\" class=\"jfDropdown-optionListItem\">Wallis and Futuna<\/li><li role=\"option\" data-value=\"Western Sahara\" class=\"jfDropdown-optionListItem\">Western Sahara<\/li><li role=\"option\" data-value=\"Yemen\" class=\"jfDropdown-optionListItem\">Yemen<\/li><li role=\"option\" data-value=\"Zambia\" class=\"jfDropdown-optionListItem\">Zambia<\/li><li role=\"option\" data-value=\"Zimbabwe\" class=\"jfDropdown-optionListItem\">Zimbabwe<\/li><li role=\"option\" data-value=\"other\" class=\"jfDropdown-optionListItem\">Other<\/li><\/ul><\/div><\/div><label class=\"jfField-sublabel \" for=\"input_21_country\" id=\"sublabel_21_country\">Country<\/label><\/div><\/div><\/div><div class=\"jfCard-actions\"><button style=\"display:block\" type=\"button\" class=\"jfInput-button forPrev u-left\" data-component=\"button\" aria-label=\"Previous\" data-testid=\"previousButton_4\">Previous<\/button><button style=\"display:block\" type=\"button\" class=\"jfInput-button forNext u-right\" data-component=\"button\" aria-label=\"Next\" data-testid=\"nextButton_4\">Next<\/button><button style=\"display:none\" type=\"submit\" class=\"jfInput-button forSubmit form-submit-button u-right\" data-component=\"button\" aria-label=\"Submit\" data-testid=\"submitButton\">Submit<\/button><div class=\"cf\"><div class=\"jfCard-actionsNotification\" aria-live=\"polite\"><div class=\"jfPressEnter isHidden\" aria-hidden=\"true\">Press<br\/>Enter<\/div><\/div><\/div><div class=\"jfCard-disableSubmitError\"><\/div><\/div><\/div><\/div><\/li><li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_32\"><div id=\"cid_32\" class=\"jfCard-wrapper\"><div class=\"jfCard\" data-type=\"control_checkbox\"><div class=\"jfCard-index\"><div>6<\/div><\/div><div class=\"jfCard-question\"><div class=\"jfQuestion-fullscreen isHidden\" aria-hidden=\"true\" role=\"button\" aria-label=\"fullscreen mode\" tabindex=\"-1\"><\/div><label for=\"input_group_32\" class=\"jfQuestion-label isLeftAlign\" id=\"label_32\"><span class=\"jsQuestionLabelContainer jfQuestionLabelContainer\">How can we help you with your smile?<\/span><\/label><span class=\"jfQuestion-description\" id=\"id_32_description\"><span><\/span><\/span><div class=\"jfCard-mobileError jsMobileErrorWrapper\"><\/div><div role=\"group\" id=\"input_group_32\" aria-describedby=\"id_32_description\" class=\"jfQuestion-fields form-multiple-column\" data-columncount=\"2\" data-component=\"checkbox\"><div class=\"jfField form-checkbox-item\"><label data-id=\"label_input_32_0\" class=\"jfCheckbox withoutImage\"><input type=\"checkbox\" class=\"jfCheckbox-input form-checkbox\" name=\"q32_howCan[]\" value=\"Restore my smile\" id=\"input_32_0\" aria-describedby=\"label_32\"\/><div class=\"jfCheckbox-label\"><span class=\"jfCheckbox-customInput\"><span class=\"jfCheckbox-customInputIcon\"><\/span><\/span><img class=\"jfCheckbox-visual\" alt=\"Checkbox\" loading=\"lazy\"\/><span class=\"jfCheckbox-labelText\">Restore my smile<\/span><\/div><\/label><\/div><div class=\"jfField form-checkbox-item\"><label data-id=\"label_input_32_1\" class=\"jfCheckbox withoutImage\"><input type=\"checkbox\" class=\"jfCheckbox-input form-checkbox\" name=\"q32_howCan[]\" value=\"Straighten my teeth\" id=\"input_32_1\" aria-describedby=\"label_32\"\/><div class=\"jfCheckbox-label\"><span class=\"jfCheckbox-customInput\"><span class=\"jfCheckbox-customInputIcon\"><\/span><\/span><img class=\"jfCheckbox-visual\" alt=\"Checkbox\" loading=\"lazy\"\/><span class=\"jfCheckbox-labelText\">Straighten my teeth<\/span><\/div><\/label><\/div><div class=\"jfField form-checkbox-item\"><label data-id=\"label_input_32_2\" class=\"jfCheckbox withoutImage\"><input type=\"checkbox\" class=\"jfCheckbox-input form-checkbox\" name=\"q32_howCan[]\" value=\"Clean my teeth\" id=\"input_32_2\" aria-describedby=\"label_32\"\/><div class=\"jfCheckbox-label\"><span class=\"jfCheckbox-customInput\"><span class=\"jfCheckbox-customInputIcon\"><\/span><\/span><img class=\"jfCheckbox-visual\" alt=\"Checkbox\" loading=\"lazy\"\/><span class=\"jfCheckbox-labelText\">Clean my teeth<\/span><\/div><\/label><\/div><div class=\"jfField form-checkbox-item\"><label data-id=\"label_input_32_3\" class=\"jfCheckbox withoutImage\"><input type=\"checkbox\" class=\"jfCheckbox-input form-checkbox\" name=\"q32_howCan[]\" value=\"Treat my gums\" id=\"input_32_3\" aria-describedby=\"label_32\"\/><div class=\"jfCheckbox-label\"><span class=\"jfCheckbox-customInput\"><span class=\"jfCheckbox-customInputIcon\"><\/span><\/span><img class=\"jfCheckbox-visual\" alt=\"Checkbox\" loading=\"lazy\"\/><span class=\"jfCheckbox-labelText\">Treat my gums<\/span><\/div><\/label><\/div><div class=\"jfField form-checkbox-item\"><label data-id=\"label_input_32_4\" class=\"jfCheckbox withoutImage\"><input type=\"checkbox\" class=\"jfCheckbox-input form-checkbox\" name=\"q32_howCan[]\" value=\"Whiten my teeth\" id=\"input_32_4\" aria-describedby=\"label_32\"\/><div class=\"jfCheckbox-label\"><span class=\"jfCheckbox-customInput\"><span class=\"jfCheckbox-customInputIcon\"><\/span><\/span><img class=\"jfCheckbox-visual\" alt=\"Checkbox\" loading=\"lazy\"\/><span class=\"jfCheckbox-labelText\">Whiten my teeth<\/span><\/div><\/label><\/div><div class=\"jfField form-checkbox-item\"><label data-id=\"label_input_32_5\" class=\"jfCheckbox withoutImage\"><input type=\"checkbox\" class=\"jfCheckbox-input form-checkbox\" name=\"q32_howCan[]\" value=\"Replace my missing teeth\" id=\"input_32_5\" aria-describedby=\"label_32\"\/><div class=\"jfCheckbox-label\"><span class=\"jfCheckbox-customInput\"><span class=\"jfCheckbox-customInputIcon\"><\/span><\/span><img class=\"jfCheckbox-visual\" alt=\"Checkbox\" loading=\"lazy\"\/><span class=\"jfCheckbox-labelText\">Replace my missing teeth<\/span><\/div><\/label><\/div><div class=\"jfField jfField-lastRowItem form-checkbox-item form-other-part-item\"><label data-id=\"label_other_32\" class=\"jfCheckbox withoutImage\"><span class=\"jfHiddenTextLabel\">Other<\/span><input type=\"checkbox\" class=\"jfCheckbox-input jfCheckbox-otherInput form-checkbox-other form-checkbox\" name=\"q32_howCan[other]\" id=\"other_32\" value=\"other\" aria-label=\"Other\"\/><div class=\"jfCheckbox-label\"><span class=\"jfCheckbox-customInput\"><span class=\"jfCheckbox-customInputIcon\"><\/span><\/span><span class=\"jfCheckbox-labelText jfCheckbox-otherInputText\"><input type=\"text\" class=\"jfCheckbox-input jfCheckbox-otherInputField form-checkbox-other-input form-textbox\" name=\"q32_howCan[other]\" data-otherhint=\"Other\" placeholder=\"Other\" size=\"15\" id=\"input_32\" aria-label=\"Other\" tabindex=\"-1\"\/><\/span><\/div><\/label><\/div><\/div><\/div><div class=\"jfCard-actions\"><button style=\"display:block\" type=\"button\" class=\"jfInput-button forPrev u-left\" data-component=\"button\" aria-label=\"Previous\" data-testid=\"previousButton_5\">Previous<\/button><button style=\"display:block\" type=\"button\" class=\"jfInput-button forNext u-right\" data-component=\"button\" aria-label=\"Next\" data-testid=\"nextButton_5\">Next<\/button><button style=\"display:none\" type=\"submit\" class=\"jfInput-button forSubmit form-submit-button u-right\" data-component=\"button\" aria-label=\"Submit\" data-testid=\"submitButton\">Submit<\/button><div class=\"cf\"><div class=\"jfCard-actionsNotification\" aria-live=\"polite\"><div class=\"jfPressEnter isHidden\" aria-hidden=\"true\">Press<br\/>Enter<\/div><\/div><\/div><div class=\"jfCard-disableSubmitError\"><\/div><\/div><\/div><\/div><\/li><li class=\"form-line\" data-type=\"control_image\" id=\"id_23\"><div id=\"cid_23\" class=\"jfCard-wrapper\"><div class=\"jfCard\" data-type=\"control_image\"><div class=\"jfCard-index\"><div>7<\/div><\/div><div class=\"jfCard-question\"><div class=\"jfQuestion-fullscreen isHidden\" aria-hidden=\"true\" role=\"button\" aria-label=\"fullscreen mode\" tabindex=\"-1\"><\/div><label for=\"input_23\" class=\"jfQuestion-label isLeftAlign\" id=\"label_23\"><span class=\"jsQuestionLabelContainer jfQuestionLabelContainer\">Please use a well lit room or your phones flash when taking the photos<\/span><\/label><span class=\"jfQuestion-description\" id=\"id_23_description\"><span>It's best to have a friend or family member help you take them<\/span><\/span><div class=\"jfCard-mobileError jsMobileErrorWrapper\"><\/div><div class=\"jfQuestion-fields\" data-component=\"image\"><div class=\"jfField\" data-type=\"image\" style=\"display:block;max-height:inherit\"><div class=\"jfImage-wrapper isCenterAlign\"><div class=\"jfImage-container\"><button type=\"button\" class=\"js-openNewTab jfImage-enlargeButton\" aria-label=\"Enlarge\"><span class=\"iconSvg  \"><svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 56.966 56.966\" style=\"enable-background:new 0 0 56.966 56.966\" xml:space=\"preserve\"><path d=\"M55.146,51.887L41.588,37.786c3.486-4.144,5.396-9.358,5.396-14.786c0-12.682-10.318-23-23-23s-23,10.318-23,23  s10.318,23,23,23c4.761,0,9.298-1.436,13.177-4.162l13.661,14.208c0.571,0.593,1.339,0.92,2.162,0.92  c0.779,0,1.518-0.297,2.079-0.837C56.255,54.982,56.293,53.08,55.146,51.887z M23.984,6c9.374,0,17,7.626,17,17s-7.626,17-17,17  s-17-7.626-17-17S14.61,6,23.984,6z\"><\/path><\/svg><\/span><\/button><img loading=\"lazy\" alt=\"\" class=\"form-image jfImage isWide\" src=\"https:\/\/www.jotform.com\/uploads\/Gladwin_James\/form_files\/natural%20light%20flash%20mob.600fdebfa98a40.31146996.png\" height=\"203px\" width=\"450px\" data-component=\"image\"\/><\/div><\/div><\/div><\/div><\/div><div class=\"jfCard-actions\"><button style=\"display:block\" type=\"button\" class=\"jfInput-button forPrev u-left\" data-component=\"button\" aria-label=\"Previous\" data-testid=\"previousButton_6\">Previous<\/button><button style=\"display:block\" type=\"button\" class=\"jfInput-button forNext u-right\" data-component=\"button\" aria-label=\"Next\" data-testid=\"nextButton_6\">Next<\/button><button style=\"display:none\" type=\"submit\" class=\"jfInput-button forSubmit form-submit-button u-right\" data-component=\"button\" aria-label=\"Submit\" data-testid=\"submitButton\">Submit<\/button><div class=\"cf\"><div class=\"jfCard-actionsNotification\" aria-live=\"polite\"><div class=\"jfPressEnter isHidden\" aria-hidden=\"true\">Press<br\/>Enter<\/div><\/div><\/div><div class=\"jfCard-disableSubmitError\"><\/div><\/div><\/div><\/div><\/li><li class=\"form-line\" data-type=\"control_image\" id=\"id_27\"><div id=\"cid_27\" class=\"jfCard-wrapper\"><div class=\"jfCard\" data-type=\"control_image\"><div class=\"jfCard-index\"><div>8<\/div><\/div><div class=\"jfCard-question\"><div class=\"jfQuestion-fullscreen isHidden\" aria-hidden=\"true\" role=\"button\" aria-label=\"fullscreen mode\" tabindex=\"-1\"><\/div><label for=\"input_27\" class=\"jfQuestion-label isLeftAlign\" id=\"label_27\"><span class=\"jsQuestionLabelContainer jfQuestionLabelContainer\">Right Side Teeth Biting<\/span><\/label><span class=\"jfQuestion-description\" id=\"id_27_description\"><span>Please capture an image that looks as close as possible to this and upload it on the next page<\/span><\/span><div class=\"jfCard-mobileError jsMobileErrorWrapper\"><\/div><div class=\"jfQuestion-fields\" data-component=\"image\"><div class=\"jfField\" data-type=\"image\" style=\"display:block;max-height:inherit\"><div class=\"jfImage-wrapper isCenterAlign\"><div class=\"jfImage-container\"><button type=\"button\" class=\"js-openNewTab jfImage-enlargeButton\" aria-label=\"Enlarge\"><span class=\"iconSvg  \"><svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 56.966 56.966\" style=\"enable-background:new 0 0 56.966 56.966\" xml:space=\"preserve\"><path d=\"M55.146,51.887L41.588,37.786c3.486-4.144,5.396-9.358,5.396-14.786c0-12.682-10.318-23-23-23s-23,10.318-23,23  s10.318,23,23,23c4.761,0,9.298-1.436,13.177-4.162l13.661,14.208c0.571,0.593,1.339,0.92,2.162,0.92  c0.779,0,1.518-0.297,2.079-0.837C56.255,54.982,56.293,53.08,55.146,51.887z M23.984,6c9.374,0,17,7.626,17,17s-7.626,17-17,17  s-17-7.626-17-17S14.61,6,23.984,6z\"><\/path><\/svg><\/span><\/button><img loading=\"lazy\" alt=\"\" class=\"form-image jfImage isWide\" src=\"https:\/\/www.jotform.com\/uploads\/Gladwin_James\/form_files\/right.600ffcb3a92534.36666682.jpg\" height=\"192px\" width=\"256px\" data-component=\"image\"\/><\/div><\/div><\/div><\/div><\/div><div class=\"jfCard-actions\"><button style=\"display:block\" type=\"button\" class=\"jfInput-button forPrev u-left\" data-component=\"button\" aria-label=\"Previous\" data-testid=\"previousButton_7\">Previous<\/button><button style=\"display:block\" type=\"button\" class=\"jfInput-button forNext u-right\" data-component=\"button\" aria-label=\"Next\" data-testid=\"nextButton_7\">Next<\/button><button style=\"display:none\" type=\"submit\" class=\"jfInput-button forSubmit form-submit-button u-right\" data-component=\"button\" aria-label=\"Submit\" data-testid=\"submitButton\">Submit<\/button><div class=\"cf\"><div class=\"jfCard-actionsNotification\" aria-live=\"polite\"><div class=\"jfPressEnter isHidden\" aria-hidden=\"true\">Press<br\/>Enter<\/div><\/div><\/div><div class=\"jfCard-disableSubmitError\"><\/div><\/div><\/div><\/div><\/li><li class=\"form-line\" data-type=\"control_fileupload\" id=\"id_8\"><div id=\"cid_8\" class=\"jfCard-wrapper\"><div class=\"jfCard\" data-type=\"control_fileupload\"><div class=\"jfCard-index\"><div>9<\/div><\/div><div class=\"jfCard-question\"><div class=\"jfQuestion-fullscreen isHidden\" aria-hidden=\"true\" role=\"button\" aria-label=\"fullscreen mode\" tabindex=\"-1\"><\/div><label for=\"input_8\" class=\"jfQuestion-label isLeftAlign\" id=\"label_8\"><span class=\"jsQuestionLabelContainer jfQuestionLabelContainer\">Right Side Teeth Biting<\/span><span class=\"jfRequiredStar\">* <span class=\"jfRequiredStar-message\">This field is required.<\/span><\/span><\/label><span class=\"jfQuestion-description\" id=\"id_8_description\"><span><\/span><\/span><div class=\"jfCard-mobileError jsMobileErrorWrapper\"><\/div><div class=\"jfQuestion-fields\" data-wrapper-react=\"true\"><div class=\"jfField isFilled\"><div class=\"jfUpload-wrapper\"><div class=\"jfUpload-container\"><div class=\"jfUpload-text-container\"><div class=\"jfUpload-icon forDesktop\"><svg width=\"54px\" height=\"47px\" viewBox=\"0 0 54 47\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><g stroke=\"none\" stroke-width=\"1\" fill=\"none\"><g transform=\"translate(-1506.000000, -2713.000000)\"><g transform=\"translate(1421.000000, 2713.000000)\"><path d=\"M125.212886,10.1718048 C127.110227,10.3826204 128.89335,10.9096517 130.562307,11.7529143 C132.231264,12.596177 133.689384,13.676591 134.93671,14.9941889 C136.184036,16.3117868 137.167828,17.8226097 137.888114,19.5267029 C138.608401,21.2307962 138.968539,23.049054 138.968539,24.9815309 C138.968539,26.8086 138.687456,28.6356416 138.125281,30.4627107 C137.563106,32.2897797 136.746207,33.9323605 135.674561,35.3905021 C134.602915,36.8486438 133.267769,38.0520318 131.669084,39.0007022 C130.070398,39.9493727 128.217005,40.4588363 126.108848,40.5291081 L122.261482,40.5291081 C121.804714,40.5291081 121.409441,40.3622149 121.07565,40.0284235 C120.741858,39.694632 120.574965,39.2993586 120.574965,38.8425913 C120.574965,38.385824 120.741858,37.9905506 121.07565,37.6567591 C121.409441,37.3229677 121.804714,37.1560744 122.261482,37.1560744 L126.108848,37.1560744 C127.549422,37.1560744 128.858216,36.7871526 130.03527,36.0492978 C131.212324,35.3114429 132.222468,34.3627867 133.06573,33.2033006 C133.908993,32.0438144 134.558998,30.743804 135.015765,29.3032303 C135.472533,27.8626567 135.700913,26.4221046 135.700913,24.9815309 C135.700913,23.4004134 135.384694,21.9159421 134.752247,20.5280723 C134.1198,19.1402026 133.258983,17.9280307 132.169768,16.8915204 C131.080554,15.85501 129.833247,15.0293277 128.427809,14.4144487 C127.022371,13.7995697 125.529116,13.4921348 123.947999,13.4921348 L122.735815,13.4394312 L122.366889,12.2799508 C121.48849,9.46907537 120.07429,7.28189569 118.124245,5.71834621 C116.1742,4.15479672 113.53026,3.37303371 110.192346,3.37303371 C108.084189,3.37303371 106.186876,3.73317173 104.500351,4.45345857 C102.813826,5.17374541 101.36449,6.17510478 100.1523,7.45756671 C98.9401098,8.74002865 98.0090213,10.2684193 97.3590063,12.0427844 C96.7089914,13.8171496 96.3839888,15.7232459 96.3839888,17.7611306 L96.4366924,17.7611306 L96.5420997,19.3422402 L95.0136938,19.6057584 C93.1514888,19.9219819 91.5703951,20.9233413 90.2703652,22.6098666 C88.9703353,24.2963919 88.3203301,26.1937043 88.3203301,28.301861 C88.3203301,30.6911051 89.1196608,32.7640947 90.7183462,34.5208919 C92.3170316,36.277689 94.2055603,37.1560744 96.3839888,37.1560744 L101.232725,37.1560744 C101.724628,37.1560744 102.128685,37.3229677 102.444909,37.6567591 C102.761132,37.9905506 102.919242,38.385824 102.919242,38.8425913 C102.919242,39.2993586 102.761132,39.694632 102.444909,40.0284235 C102.128685,40.3622149 101.724628,40.5291081 101.232725,40.5291081 L96.3839888,40.5291081 C94.8380073,40.5291081 93.3798875,40.2041055 92.0095857,39.5540906 C90.6392839,38.9040756 89.4358959,38.0169064 88.3993855,36.8925562 C87.3628752,35.768206 86.5371929,34.4681956 85.9223139,32.992486 C85.3074349,31.5167763 85,29.9532503 85,28.301861 C85,25.5963933 85.7554115,23.1544819 87.266257,20.9760534 C88.7771026,18.7976249 90.7095505,17.3395051 93.0636587,16.6016503 C93.2042025,14.2475421 93.7224499,12.0603624 94.6184164,10.0400456 C95.514383,8.0197289 96.7089871,6.26295807 98.2022647,4.76968048 C99.6955423,3.27640288 101.452313,2.10815028 103.47263,1.26488764 C105.492947,0.421624997 107.732829,0 110.192346,0 C112.089686,0 113.82889,0.237164061 115.410007,0.711499298 C116.991124,1.18583453 118.414109,1.8621913 119.679003,2.74058989 C120.943897,3.61898847 122.033095,4.69061868 122.946629,5.95551264 C123.860164,7.22040661 124.615575,8.62582326 125.212886,10.1718048 Z M113.249157,23.611236 L119.468188,30.4627107 C119.71414,30.7086623 119.837114,30.9985295 119.837114,31.3323209 C119.837114,31.6661124 119.71414,31.9735473 119.468188,32.2546348 L119.046559,32.5181531 C118.835743,32.7641047 118.563444,32.8607271 118.229652,32.8080232 C117.895861,32.7553193 117.605994,32.6059937 117.360042,32.3600421 L113.670787,28.2491573 L113.670787,45.2197331 C113.670787,45.7116364 113.503893,46.1156936 113.170102,46.4319171 C112.83631,46.7481406 112.441037,46.90625 111.98427,46.90625 C111.492366,46.90625 111.088309,46.7481406 110.772086,46.4319171 C110.455862,46.1156936 110.297753,45.7116364 110.297753,45.2197331 L110.297753,28.2491573 L106.713904,32.2546348 C106.467953,32.5005864 106.178086,32.649912 105.844294,32.7026159 C105.510503,32.7553198 105.220636,32.6586974 104.974684,32.4127458 L104.553055,32.1492275 C104.307103,31.86814 104.184129,31.5607051 104.184129,31.2269136 C104.184129,30.8931222 104.307103,30.603255 104.553055,30.3573034 L110.666678,23.611236 L110.666678,23.5585323 L111.088308,23.1369031 C111.193715,22.9963593 111.325473,22.8997369 111.483585,22.847033 C111.641697,22.7943291 111.791022,22.7679775 111.931566,22.7679775 C112.107246,22.7679775 112.265355,22.7943291 112.405899,22.847033 C112.546443,22.8997369 112.686984,22.9963593 112.827528,23.1369031 L113.249157,23.5585323 L113.249157,23.611236 Z\"><\/path><\/g><\/g><\/g><\/svg><\/div><div class=\"jfUpload-text\"><div class=\"jfUpload-heading forDesktop\">Drag and drop files here<\/div><div class=\"jfUpload-heading forMobile\">Select files to upload<\/div><div class=\"jfUpload-subheading\" style=\"display:\"><span><span class=\"maxFileSize\">Max. file size<\/span>: 10.6MB<\/span><\/div><\/div><\/div><div class=\"jfUpload-button-container\"><label class=\"jfUpload-button\" aria-hidden=\"true\" tabindex=\"0\" for=\"input_8\">Browse Files<\/label><\/div><\/div><div class=\"jfUpload-files-container\"><input type=\"file\" id=\"input_8\" name=\"q8_rightSide8[]\" multiple=\"\" class=\"form-upload-multiple validate[required]\" data-imagevalidate=\"yes\" data-file-accept=\"pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif\" data-file-maxsize=\"10854\" data-file-minsize=\"0\" data-file-limit=\"\" data-component=\"fileupload\" required=\"\" aria-label=\"Browse Files\"\/><\/div><\/div><label class=\"jfField-sublabel \" for=\"input_8\" aria-hidden=\"true\" tabindex=\"-1\"><\/label><\/div><span style=\"display:none\" class=\"cancelText\">Cancel<\/span><span style=\"display:none\" class=\"ofText\">of<\/span><\/div><\/div><div class=\"jfCard-actions\"><button style=\"display:block\" type=\"button\" class=\"jfInput-button forPrev u-left\" data-component=\"button\" aria-label=\"Previous\" data-testid=\"previousButton_8\">Previous<\/button><button style=\"display:block\" type=\"button\" class=\"jfInput-button forNext u-right\" data-component=\"button\" aria-label=\"Next\" data-testid=\"nextButton_8\">Next<\/button><button style=\"display:none\" type=\"submit\" class=\"jfInput-button forSubmit form-submit-button u-right\" data-component=\"button\" aria-label=\"Submit\" data-testid=\"submitButton\">Submit<\/button><div class=\"cf\"><div class=\"jfCard-actionsNotification\" aria-live=\"polite\"><div class=\"jfPressEnter isHidden\" aria-hidden=\"true\">Press<br\/>Enter<\/div><\/div><\/div><div class=\"jfCard-disableSubmitError\"><\/div><\/div><\/div><\/div><\/li><li class=\"form-line\" data-type=\"control_image\" id=\"id_28\"><div id=\"cid_28\" class=\"jfCard-wrapper\"><div class=\"jfCard\" data-type=\"control_image\"><div class=\"jfCard-index\"><div>10<\/div><\/div><div class=\"jfCard-question\"><div class=\"jfQuestion-fullscreen isHidden\" aria-hidden=\"true\" role=\"button\" aria-label=\"fullscreen mode\" tabindex=\"-1\"><\/div><label for=\"input_28\" class=\"jfQuestion-label isLeftAlign\" id=\"label_28\"><span class=\"jsQuestionLabelContainer jfQuestionLabelContainer\">Left Side Teeth Biting<\/span><\/label><span class=\"jfQuestion-description\" id=\"id_28_description\"><span>Please capture an image that looks as close as possible to this and upload it on the next page<\/span><\/span><div class=\"jfCard-mobileError jsMobileErrorWrapper\"><\/div><div class=\"jfQuestion-fields\" data-component=\"image\"><div class=\"jfField\" data-type=\"image\" style=\"display:block;max-height:inherit\"><div class=\"jfImage-wrapper isCenterAlign\"><div class=\"jfImage-container\"><button type=\"button\" class=\"js-openNewTab jfImage-enlargeButton\" aria-label=\"Enlarge\"><span class=\"iconSvg  \"><svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 56.966 56.966\" style=\"enable-background:new 0 0 56.966 56.966\" xml:space=\"preserve\"><path d=\"M55.146,51.887L41.588,37.786c3.486-4.144,5.396-9.358,5.396-14.786c0-12.682-10.318-23-23-23s-23,10.318-23,23  s10.318,23,23,23c4.761,0,9.298-1.436,13.177-4.162l13.661,14.208c0.571,0.593,1.339,0.92,2.162,0.92  c0.779,0,1.518-0.297,2.079-0.837C56.255,54.982,56.293,53.08,55.146,51.887z M23.984,6c9.374,0,17,7.626,17,17s-7.626,17-17,17  s-17-7.626-17-17S14.61,6,23.984,6z\"><\/path><\/svg><\/span><\/button><img loading=\"lazy\" alt=\"\" class=\"form-image jfImage isWide\" src=\"https:\/\/www.jotform.com\/uploads\/Gladwin_James\/form_files\/left.600ffe48830614.46436307.jpg\" height=\"192px\" width=\"256px\" data-component=\"image\"\/><\/div><\/div><\/div><\/div><\/div><div class=\"jfCard-actions\"><button style=\"display:block\" type=\"button\" class=\"jfInput-button forPrev u-left\" data-component=\"button\" aria-label=\"Previous\" data-testid=\"previousButton_9\">Previous<\/button><button style=\"display:block\" type=\"button\" class=\"jfInput-button forNext u-right\" data-component=\"button\" aria-label=\"Next\" data-testid=\"nextButton_9\">Next<\/button><button style=\"display:none\" type=\"submit\" class=\"jfInput-button forSubmit form-submit-button u-right\" data-component=\"button\" aria-label=\"Submit\" data-testid=\"submitButton\">Submit<\/button><div class=\"cf\"><div class=\"jfCard-actionsNotification\" aria-live=\"polite\"><div class=\"jfPressEnter isHidden\" aria-hidden=\"true\">Press<br\/>Enter<\/div><\/div><\/div><div class=\"jfCard-disableSubmitError\"><\/div><\/div><\/div><\/div><\/li><li class=\"form-line\" data-type=\"control_fileupload\" id=\"id_9\"><div id=\"cid_9\" class=\"jfCard-wrapper\"><div class=\"jfCard\" data-type=\"control_fileupload\"><div class=\"jfCard-index\"><div>11<\/div><\/div><div class=\"jfCard-question\"><div class=\"jfQuestion-fullscreen isHidden\" aria-hidden=\"true\" role=\"button\" aria-label=\"fullscreen mode\" tabindex=\"-1\"><\/div><label for=\"input_9\" class=\"jfQuestion-label isLeftAlign\" id=\"label_9\"><span class=\"jsQuestionLabelContainer jfQuestionLabelContainer\">Left Side Teeth Biting<\/span><span class=\"jfRequiredStar\">* <span class=\"jfRequiredStar-message\">This field is required.<\/span><\/span><\/label><span class=\"jfQuestion-description\" id=\"id_9_description\"><span><\/span><\/span><div class=\"jfCard-mobileError jsMobileErrorWrapper\"><\/div><div class=\"jfQuestion-fields\" data-wrapper-react=\"true\"><div class=\"jfField isFilled\"><div class=\"jfUpload-wrapper\"><div class=\"jfUpload-container\"><div class=\"jfUpload-text-container\"><div class=\"jfUpload-icon forDesktop\"><svg width=\"54px\" height=\"47px\" viewBox=\"0 0 54 47\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><g stroke=\"none\" stroke-width=\"1\" fill=\"none\"><g transform=\"translate(-1506.000000, -2713.000000)\"><g transform=\"translate(1421.000000, 2713.000000)\"><path d=\"M125.212886,10.1718048 C127.110227,10.3826204 128.89335,10.9096517 130.562307,11.7529143 C132.231264,12.596177 133.689384,13.676591 134.93671,14.9941889 C136.184036,16.3117868 137.167828,17.8226097 137.888114,19.5267029 C138.608401,21.2307962 138.968539,23.049054 138.968539,24.9815309 C138.968539,26.8086 138.687456,28.6356416 138.125281,30.4627107 C137.563106,32.2897797 136.746207,33.9323605 135.674561,35.3905021 C134.602915,36.8486438 133.267769,38.0520318 131.669084,39.0007022 C130.070398,39.9493727 128.217005,40.4588363 126.108848,40.5291081 L122.261482,40.5291081 C121.804714,40.5291081 121.409441,40.3622149 121.07565,40.0284235 C120.741858,39.694632 120.574965,39.2993586 120.574965,38.8425913 C120.574965,38.385824 120.741858,37.9905506 121.07565,37.6567591 C121.409441,37.3229677 121.804714,37.1560744 122.261482,37.1560744 L126.108848,37.1560744 C127.549422,37.1560744 128.858216,36.7871526 130.03527,36.0492978 C131.212324,35.3114429 132.222468,34.3627867 133.06573,33.2033006 C133.908993,32.0438144 134.558998,30.743804 135.015765,29.3032303 C135.472533,27.8626567 135.700913,26.4221046 135.700913,24.9815309 C135.700913,23.4004134 135.384694,21.9159421 134.752247,20.5280723 C134.1198,19.1402026 133.258983,17.9280307 132.169768,16.8915204 C131.080554,15.85501 129.833247,15.0293277 128.427809,14.4144487 C127.022371,13.7995697 125.529116,13.4921348 123.947999,13.4921348 L122.735815,13.4394312 L122.366889,12.2799508 C121.48849,9.46907537 120.07429,7.28189569 118.124245,5.71834621 C116.1742,4.15479672 113.53026,3.37303371 110.192346,3.37303371 C108.084189,3.37303371 106.186876,3.73317173 104.500351,4.45345857 C102.813826,5.17374541 101.36449,6.17510478 100.1523,7.45756671 C98.9401098,8.74002865 98.0090213,10.2684193 97.3590063,12.0427844 C96.7089914,13.8171496 96.3839888,15.7232459 96.3839888,17.7611306 L96.4366924,17.7611306 L96.5420997,19.3422402 L95.0136938,19.6057584 C93.1514888,19.9219819 91.5703951,20.9233413 90.2703652,22.6098666 C88.9703353,24.2963919 88.3203301,26.1937043 88.3203301,28.301861 C88.3203301,30.6911051 89.1196608,32.7640947 90.7183462,34.5208919 C92.3170316,36.277689 94.2055603,37.1560744 96.3839888,37.1560744 L101.232725,37.1560744 C101.724628,37.1560744 102.128685,37.3229677 102.444909,37.6567591 C102.761132,37.9905506 102.919242,38.385824 102.919242,38.8425913 C102.919242,39.2993586 102.761132,39.694632 102.444909,40.0284235 C102.128685,40.3622149 101.724628,40.5291081 101.232725,40.5291081 L96.3839888,40.5291081 C94.8380073,40.5291081 93.3798875,40.2041055 92.0095857,39.5540906 C90.6392839,38.9040756 89.4358959,38.0169064 88.3993855,36.8925562 C87.3628752,35.768206 86.5371929,34.4681956 85.9223139,32.992486 C85.3074349,31.5167763 85,29.9532503 85,28.301861 C85,25.5963933 85.7554115,23.1544819 87.266257,20.9760534 C88.7771026,18.7976249 90.7095505,17.3395051 93.0636587,16.6016503 C93.2042025,14.2475421 93.7224499,12.0603624 94.6184164,10.0400456 C95.514383,8.0197289 96.7089871,6.26295807 98.2022647,4.76968048 C99.6955423,3.27640288 101.452313,2.10815028 103.47263,1.26488764 C105.492947,0.421624997 107.732829,0 110.192346,0 C112.089686,0 113.82889,0.237164061 115.410007,0.711499298 C116.991124,1.18583453 118.414109,1.8621913 119.679003,2.74058989 C120.943897,3.61898847 122.033095,4.69061868 122.946629,5.95551264 C123.860164,7.22040661 124.615575,8.62582326 125.212886,10.1718048 Z M113.249157,23.611236 L119.468188,30.4627107 C119.71414,30.7086623 119.837114,30.9985295 119.837114,31.3323209 C119.837114,31.6661124 119.71414,31.9735473 119.468188,32.2546348 L119.046559,32.5181531 C118.835743,32.7641047 118.563444,32.8607271 118.229652,32.8080232 C117.895861,32.7553193 117.605994,32.6059937 117.360042,32.3600421 L113.670787,28.2491573 L113.670787,45.2197331 C113.670787,45.7116364 113.503893,46.1156936 113.170102,46.4319171 C112.83631,46.7481406 112.441037,46.90625 111.98427,46.90625 C111.492366,46.90625 111.088309,46.7481406 110.772086,46.4319171 C110.455862,46.1156936 110.297753,45.7116364 110.297753,45.2197331 L110.297753,28.2491573 L106.713904,32.2546348 C106.467953,32.5005864 106.178086,32.649912 105.844294,32.7026159 C105.510503,32.7553198 105.220636,32.6586974 104.974684,32.4127458 L104.553055,32.1492275 C104.307103,31.86814 104.184129,31.5607051 104.184129,31.2269136 C104.184129,30.8931222 104.307103,30.603255 104.553055,30.3573034 L110.666678,23.611236 L110.666678,23.5585323 L111.088308,23.1369031 C111.193715,22.9963593 111.325473,22.8997369 111.483585,22.847033 C111.641697,22.7943291 111.791022,22.7679775 111.931566,22.7679775 C112.107246,22.7679775 112.265355,22.7943291 112.405899,22.847033 C112.546443,22.8997369 112.686984,22.9963593 112.827528,23.1369031 L113.249157,23.5585323 L113.249157,23.611236 Z\"><\/path><\/g><\/g><\/g><\/svg><\/div><div class=\"jfUpload-text\"><div class=\"jfUpload-heading forDesktop\">Drag and drop files here<\/div><div class=\"jfUpload-heading forMobile\">Select files to upload<\/div><div class=\"jfUpload-subheading\" style=\"display:\"><span><span class=\"maxFileSize\">Max. file size<\/span>: 10.6MB<\/span><\/div><\/div><\/div><div class=\"jfUpload-button-container\"><label class=\"jfUpload-button\" aria-hidden=\"true\" tabindex=\"0\" for=\"input_9\">Browse Files<\/label><\/div><\/div><div class=\"jfUpload-files-container\"><input type=\"file\" id=\"input_9\" name=\"q9_leftSide9[]\" multiple=\"\" class=\"form-upload-multiple validate[required]\" data-imagevalidate=\"yes\" data-file-accept=\"pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif\" data-file-maxsize=\"10854\" data-file-minsize=\"0\" data-file-limit=\"\" data-component=\"fileupload\" required=\"\" aria-label=\"Browse Files\"\/><\/div><\/div><label class=\"jfField-sublabel \" for=\"input_9\" aria-hidden=\"true\" tabindex=\"-1\"><\/label><\/div><span style=\"display:none\" class=\"cancelText\">Cancel<\/span><span style=\"display:none\" class=\"ofText\">of<\/span><\/div><\/div><div class=\"jfCard-actions\"><button style=\"display:block\" type=\"button\" class=\"jfInput-button forPrev u-left\" data-component=\"button\" aria-label=\"Previous\" data-testid=\"previousButton_10\">Previous<\/button><button style=\"display:block\" type=\"button\" class=\"jfInput-button forNext u-right\" data-component=\"button\" aria-label=\"Next\" data-testid=\"nextButton_10\">Next<\/button><button style=\"display:none\" type=\"submit\" class=\"jfInput-button forSubmit form-submit-button u-right\" data-component=\"button\" aria-label=\"Submit\" data-testid=\"submitButton\">Submit<\/button><div class=\"cf\"><div class=\"jfCard-actionsNotification\" aria-live=\"polite\"><div class=\"jfPressEnter isHidden\" aria-hidden=\"true\">Press<br\/>Enter<\/div><\/div><\/div><div class=\"jfCard-disableSubmitError\"><\/div><\/div><\/div><\/div><\/li><li class=\"form-line\" data-type=\"control_image\" id=\"id_29\"><div id=\"cid_29\" class=\"jfCard-wrapper\"><div class=\"jfCard\" data-type=\"control_image\"><div class=\"jfCard-index\"><div>12<\/div><\/div><div class=\"jfCard-question\"><div class=\"jfQuestion-fullscreen isHidden\" aria-hidden=\"true\" role=\"button\" aria-label=\"fullscreen mode\" tabindex=\"-1\"><\/div><label for=\"input_29\" class=\"jfQuestion-label isLeftAlign\" id=\"label_29\"><span class=\"jsQuestionLabelContainer jfQuestionLabelContainer\">Front Teeth Biting<\/span><\/label><span class=\"jfQuestion-description\" id=\"id_29_description\"><span>Please capture an image that looks as close as possible to this and upload it on the next page<\/span><\/span><div class=\"jfCard-mobileError jsMobileErrorWrapper\"><\/div><div class=\"jfQuestion-fields\" data-component=\"image\"><div class=\"jfField\" data-type=\"image\" style=\"display:block;max-height:inherit\"><div class=\"jfImage-wrapper isCenterAlign\"><div class=\"jfImage-container\"><button type=\"button\" class=\"js-openNewTab jfImage-enlargeButton\" aria-label=\"Enlarge\"><span class=\"iconSvg  \"><svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 56.966 56.966\" style=\"enable-background:new 0 0 56.966 56.966\" xml:space=\"preserve\"><path d=\"M55.146,51.887L41.588,37.786c3.486-4.144,5.396-9.358,5.396-14.786c0-12.682-10.318-23-23-23s-23,10.318-23,23  s10.318,23,23,23c4.761,0,9.298-1.436,13.177-4.162l13.661,14.208c0.571,0.593,1.339,0.92,2.162,0.92  c0.779,0,1.518-0.297,2.079-0.837C56.255,54.982,56.293,53.08,55.146,51.887z M23.984,6c9.374,0,17,7.626,17,17s-7.626,17-17,17  s-17-7.626-17-17S14.61,6,23.984,6z\"><\/path><\/svg><\/span><\/button><img loading=\"lazy\" alt=\"\" class=\"form-image jfImage isWide\" src=\"https:\/\/www.jotform.com\/uploads\/Gladwin_James\/form_files\/front.600fff1a540881.88383205.jpg\" height=\"192px\" width=\"256px\" data-component=\"image\"\/><\/div><\/div><\/div><\/div><\/div><div class=\"jfCard-actions\"><button style=\"display:block\" type=\"button\" class=\"jfInput-button forPrev u-left\" data-component=\"button\" aria-label=\"Previous\" data-testid=\"previousButton_11\">Previous<\/button><button style=\"display:block\" type=\"button\" class=\"jfInput-button forNext u-right\" data-component=\"button\" aria-label=\"Next\" data-testid=\"nextButton_11\">Next<\/button><button style=\"display:none\" type=\"submit\" class=\"jfInput-button forSubmit form-submit-button u-right\" data-component=\"button\" aria-label=\"Submit\" data-testid=\"submitButton\">Submit<\/button><div class=\"cf\"><div class=\"jfCard-actionsNotification\" aria-live=\"polite\"><div class=\"jfPressEnter isHidden\" aria-hidden=\"true\">Press<br\/>Enter<\/div><\/div><\/div><div class=\"jfCard-disableSubmitError\"><\/div><\/div><\/div><\/div><\/li><li class=\"form-line\" data-type=\"control_fileupload\" id=\"id_10\"><div id=\"cid_10\" class=\"jfCard-wrapper\"><div class=\"jfCard\" data-type=\"control_fileupload\"><div class=\"jfCard-index\"><div>13<\/div><\/div><div class=\"jfCard-question\"><div class=\"jfQuestion-fullscreen isHidden\" aria-hidden=\"true\" role=\"button\" aria-label=\"fullscreen mode\" tabindex=\"-1\"><\/div><label for=\"input_10\" class=\"jfQuestion-label isLeftAlign\" id=\"label_10\"><span class=\"jsQuestionLabelContainer jfQuestionLabelContainer\">Front Teeth Biting<\/span><span class=\"jfRequiredStar\">* <span class=\"jfRequiredStar-message\">This field is required.<\/span><\/span><\/label><span class=\"jfQuestion-description\" id=\"id_10_description\"><span><\/span><\/span><div class=\"jfCard-mobileError jsMobileErrorWrapper\"><\/div><div class=\"jfQuestion-fields\" data-wrapper-react=\"true\"><div class=\"jfField isFilled\"><div class=\"jfUpload-wrapper\"><div class=\"jfUpload-container\"><div class=\"jfUpload-text-container\"><div class=\"jfUpload-icon forDesktop\"><svg width=\"54px\" height=\"47px\" viewBox=\"0 0 54 47\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><g stroke=\"none\" stroke-width=\"1\" fill=\"none\"><g transform=\"translate(-1506.000000, -2713.000000)\"><g transform=\"translate(1421.000000, 2713.000000)\"><path d=\"M125.212886,10.1718048 C127.110227,10.3826204 128.89335,10.9096517 130.562307,11.7529143 C132.231264,12.596177 133.689384,13.676591 134.93671,14.9941889 C136.184036,16.3117868 137.167828,17.8226097 137.888114,19.5267029 C138.608401,21.2307962 138.968539,23.049054 138.968539,24.9815309 C138.968539,26.8086 138.687456,28.6356416 138.125281,30.4627107 C137.563106,32.2897797 136.746207,33.9323605 135.674561,35.3905021 C134.602915,36.8486438 133.267769,38.0520318 131.669084,39.0007022 C130.070398,39.9493727 128.217005,40.4588363 126.108848,40.5291081 L122.261482,40.5291081 C121.804714,40.5291081 121.409441,40.3622149 121.07565,40.0284235 C120.741858,39.694632 120.574965,39.2993586 120.574965,38.8425913 C120.574965,38.385824 120.741858,37.9905506 121.07565,37.6567591 C121.409441,37.3229677 121.804714,37.1560744 122.261482,37.1560744 L126.108848,37.1560744 C127.549422,37.1560744 128.858216,36.7871526 130.03527,36.0492978 C131.212324,35.3114429 132.222468,34.3627867 133.06573,33.2033006 C133.908993,32.0438144 134.558998,30.743804 135.015765,29.3032303 C135.472533,27.8626567 135.700913,26.4221046 135.700913,24.9815309 C135.700913,23.4004134 135.384694,21.9159421 134.752247,20.5280723 C134.1198,19.1402026 133.258983,17.9280307 132.169768,16.8915204 C131.080554,15.85501 129.833247,15.0293277 128.427809,14.4144487 C127.022371,13.7995697 125.529116,13.4921348 123.947999,13.4921348 L122.735815,13.4394312 L122.366889,12.2799508 C121.48849,9.46907537 120.07429,7.28189569 118.124245,5.71834621 C116.1742,4.15479672 113.53026,3.37303371 110.192346,3.37303371 C108.084189,3.37303371 106.186876,3.73317173 104.500351,4.45345857 C102.813826,5.17374541 101.36449,6.17510478 100.1523,7.45756671 C98.9401098,8.74002865 98.0090213,10.2684193 97.3590063,12.0427844 C96.7089914,13.8171496 96.3839888,15.7232459 96.3839888,17.7611306 L96.4366924,17.7611306 L96.5420997,19.3422402 L95.0136938,19.6057584 C93.1514888,19.9219819 91.5703951,20.9233413 90.2703652,22.6098666 C88.9703353,24.2963919 88.3203301,26.1937043 88.3203301,28.301861 C88.3203301,30.6911051 89.1196608,32.7640947 90.7183462,34.5208919 C92.3170316,36.277689 94.2055603,37.1560744 96.3839888,37.1560744 L101.232725,37.1560744 C101.724628,37.1560744 102.128685,37.3229677 102.444909,37.6567591 C102.761132,37.9905506 102.919242,38.385824 102.919242,38.8425913 C102.919242,39.2993586 102.761132,39.694632 102.444909,40.0284235 C102.128685,40.3622149 101.724628,40.5291081 101.232725,40.5291081 L96.3839888,40.5291081 C94.8380073,40.5291081 93.3798875,40.2041055 92.0095857,39.5540906 C90.6392839,38.9040756 89.4358959,38.0169064 88.3993855,36.8925562 C87.3628752,35.768206 86.5371929,34.4681956 85.9223139,32.992486 C85.3074349,31.5167763 85,29.9532503 85,28.301861 C85,25.5963933 85.7554115,23.1544819 87.266257,20.9760534 C88.7771026,18.7976249 90.7095505,17.3395051 93.0636587,16.6016503 C93.2042025,14.2475421 93.7224499,12.0603624 94.6184164,10.0400456 C95.514383,8.0197289 96.7089871,6.26295807 98.2022647,4.76968048 C99.6955423,3.27640288 101.452313,2.10815028 103.47263,1.26488764 C105.492947,0.421624997 107.732829,0 110.192346,0 C112.089686,0 113.82889,0.237164061 115.410007,0.711499298 C116.991124,1.18583453 118.414109,1.8621913 119.679003,2.74058989 C120.943897,3.61898847 122.033095,4.69061868 122.946629,5.95551264 C123.860164,7.22040661 124.615575,8.62582326 125.212886,10.1718048 Z M113.249157,23.611236 L119.468188,30.4627107 C119.71414,30.7086623 119.837114,30.9985295 119.837114,31.3323209 C119.837114,31.6661124 119.71414,31.9735473 119.468188,32.2546348 L119.046559,32.5181531 C118.835743,32.7641047 118.563444,32.8607271 118.229652,32.8080232 C117.895861,32.7553193 117.605994,32.6059937 117.360042,32.3600421 L113.670787,28.2491573 L113.670787,45.2197331 C113.670787,45.7116364 113.503893,46.1156936 113.170102,46.4319171 C112.83631,46.7481406 112.441037,46.90625 111.98427,46.90625 C111.492366,46.90625 111.088309,46.7481406 110.772086,46.4319171 C110.455862,46.1156936 110.297753,45.7116364 110.297753,45.2197331 L110.297753,28.2491573 L106.713904,32.2546348 C106.467953,32.5005864 106.178086,32.649912 105.844294,32.7026159 C105.510503,32.7553198 105.220636,32.6586974 104.974684,32.4127458 L104.553055,32.1492275 C104.307103,31.86814 104.184129,31.5607051 104.184129,31.2269136 C104.184129,30.8931222 104.307103,30.603255 104.553055,30.3573034 L110.666678,23.611236 L110.666678,23.5585323 L111.088308,23.1369031 C111.193715,22.9963593 111.325473,22.8997369 111.483585,22.847033 C111.641697,22.7943291 111.791022,22.7679775 111.931566,22.7679775 C112.107246,22.7679775 112.265355,22.7943291 112.405899,22.847033 C112.546443,22.8997369 112.686984,22.9963593 112.827528,23.1369031 L113.249157,23.5585323 L113.249157,23.611236 Z\"><\/path><\/g><\/g><\/g><\/svg><\/div><div class=\"jfUpload-text\"><div class=\"jfUpload-heading forDesktop\">Drag and drop files here<\/div><div class=\"jfUpload-heading forMobile\">Select files to upload<\/div><div class=\"jfUpload-subheading\" style=\"display:\"><span><span class=\"maxFileSize\">Max. file size<\/span>: 10.6MB<\/span><\/div><\/div><\/div><div class=\"jfUpload-button-container\"><label class=\"jfUpload-button\" aria-hidden=\"true\" tabindex=\"0\" for=\"input_10\">Browse Files<\/label><\/div><\/div><div class=\"jfUpload-files-container\"><input type=\"file\" id=\"input_10\" name=\"q10_frontTeeth[]\" multiple=\"\" class=\"form-upload-multiple validate[required]\" data-imagevalidate=\"yes\" data-file-accept=\"pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif\" data-file-maxsize=\"10854\" data-file-minsize=\"0\" data-file-limit=\"\" data-component=\"fileupload\" required=\"\" aria-label=\"Browse Files\"\/><\/div><\/div><label class=\"jfField-sublabel \" for=\"input_10\" aria-hidden=\"true\" tabindex=\"-1\"><\/label><\/div><span style=\"display:none\" class=\"cancelText\">Cancel<\/span><span style=\"display:none\" class=\"ofText\">of<\/span><\/div><\/div><div class=\"jfCard-actions\"><button style=\"display:block\" type=\"button\" class=\"jfInput-button forPrev u-left\" data-component=\"button\" aria-label=\"Previous\" data-testid=\"previousButton_12\">Previous<\/button><button style=\"display:block\" type=\"button\" class=\"jfInput-button forNext u-right\" data-component=\"button\" aria-label=\"Next\" data-testid=\"nextButton_12\">Next<\/button><button style=\"display:none\" type=\"submit\" class=\"jfInput-button forSubmit form-submit-button u-right\" data-component=\"button\" aria-label=\"Submit\" data-testid=\"submitButton\">Submit<\/button><div class=\"cf\"><div class=\"jfCard-actionsNotification\" aria-live=\"polite\"><div class=\"jfPressEnter isHidden\" aria-hidden=\"true\">Press<br\/>Enter<\/div><\/div><\/div><div class=\"jfCard-disableSubmitError\"><\/div><\/div><\/div><\/div><\/li><li class=\"form-line\" data-type=\"control_image\" id=\"id_30\"><div id=\"cid_30\" class=\"jfCard-wrapper\"><div class=\"jfCard\" data-type=\"control_image\"><div class=\"jfCard-index\"><div>14<\/div><\/div><div class=\"jfCard-question\"><div class=\"jfQuestion-fullscreen isHidden\" aria-hidden=\"true\" role=\"button\" aria-label=\"fullscreen mode\" tabindex=\"-1\"><\/div><label for=\"input_30\" class=\"jfQuestion-label isLeftAlign\" id=\"label_30\"><span class=\"jsQuestionLabelContainer jfQuestionLabelContainer\">Upper Teeth Apart<\/span><\/label><span class=\"jfQuestion-description\" id=\"id_30_description\"><span>Please capture an image that looks as close as possible to this and upload it on the next page<\/span><\/span><div class=\"jfCard-mobileError jsMobileErrorWrapper\"><\/div><div class=\"jfQuestion-fields\" data-component=\"image\"><div class=\"jfField\" data-type=\"image\" style=\"display:block;max-height:inherit\"><div class=\"jfImage-wrapper isCenterAlign\"><div class=\"jfImage-container\"><button type=\"button\" class=\"js-openNewTab jfImage-enlargeButton\" aria-label=\"Enlarge\"><span class=\"iconSvg  \"><svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 56.966 56.966\" style=\"enable-background:new 0 0 56.966 56.966\" xml:space=\"preserve\"><path d=\"M55.146,51.887L41.588,37.786c3.486-4.144,5.396-9.358,5.396-14.786c0-12.682-10.318-23-23-23s-23,10.318-23,23  s10.318,23,23,23c4.761,0,9.298-1.436,13.177-4.162l13.661,14.208c0.571,0.593,1.339,0.92,2.162,0.92  c0.779,0,1.518-0.297,2.079-0.837C56.255,54.982,56.293,53.08,55.146,51.887z M23.984,6c9.374,0,17,7.626,17,17s-7.626,17-17,17  s-17-7.626-17-17S14.61,6,23.984,6z\"><\/path><\/svg><\/span><\/button><img loading=\"lazy\" alt=\"\" class=\"form-image jfImage isWide\" src=\"https:\/\/www.jotform.com\/uploads\/Gladwin_James\/form_files\/top.600fff52d8e942.12045737.jpg\" height=\"192px\" width=\"256px\" data-component=\"image\"\/><\/div><\/div><\/div><\/div><\/div><div class=\"jfCard-actions\"><button style=\"display:block\" type=\"button\" class=\"jfInput-button forPrev u-left\" data-component=\"button\" aria-label=\"Previous\" data-testid=\"previousButton_13\">Previous<\/button><button style=\"display:block\" type=\"button\" class=\"jfInput-button forNext u-right\" data-component=\"button\" aria-label=\"Next\" data-testid=\"nextButton_13\">Next<\/button><button style=\"display:none\" type=\"submit\" class=\"jfInput-button forSubmit form-submit-button u-right\" data-component=\"button\" aria-label=\"Submit\" data-testid=\"submitButton\">Submit<\/button><div class=\"cf\"><div class=\"jfCard-actionsNotification\" 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133.267769,38.0520318 131.669084,39.0007022 C130.070398,39.9493727 128.217005,40.4588363 126.108848,40.5291081 L122.261482,40.5291081 C121.804714,40.5291081 121.409441,40.3622149 121.07565,40.0284235 C120.741858,39.694632 120.574965,39.2993586 120.574965,38.8425913 C120.574965,38.385824 120.741858,37.9905506 121.07565,37.6567591 C121.409441,37.3229677 121.804714,37.1560744 122.261482,37.1560744 L126.108848,37.1560744 C127.549422,37.1560744 128.858216,36.7871526 130.03527,36.0492978 C131.212324,35.3114429 132.222468,34.3627867 133.06573,33.2033006 C133.908993,32.0438144 134.558998,30.743804 135.015765,29.3032303 C135.472533,27.8626567 135.700913,26.4221046 135.700913,24.9815309 C135.700913,23.4004134 135.384694,21.9159421 134.752247,20.5280723 C134.1198,19.1402026 133.258983,17.9280307 132.169768,16.8915204 C131.080554,15.85501 129.833247,15.0293277 128.427809,14.4144487 C127.022371,13.7995697 125.529116,13.4921348 123.947999,13.4921348 L122.735815,13.4394312 L122.366889,12.2799508 C121.48849,9.46907537 120.07429,7.28189569 118.124245,5.71834621 C116.1742,4.15479672 113.53026,3.37303371 110.192346,3.37303371 C108.084189,3.37303371 106.186876,3.73317173 104.500351,4.45345857 C102.813826,5.17374541 101.36449,6.17510478 100.1523,7.45756671 C98.9401098,8.74002865 98.0090213,10.2684193 97.3590063,12.0427844 C96.7089914,13.8171496 96.3839888,15.7232459 96.3839888,17.7611306 L96.4366924,17.7611306 L96.5420997,19.3422402 L95.0136938,19.6057584 C93.1514888,19.9219819 91.5703951,20.9233413 90.2703652,22.6098666 C88.9703353,24.2963919 88.3203301,26.1937043 88.3203301,28.301861 C88.3203301,30.6911051 89.1196608,32.7640947 90.7183462,34.5208919 C92.3170316,36.277689 94.2055603,37.1560744 96.3839888,37.1560744 L101.232725,37.1560744 C101.724628,37.1560744 102.128685,37.3229677 102.444909,37.6567591 C102.761132,37.9905506 102.919242,38.385824 102.919242,38.8425913 C102.919242,39.2993586 102.761132,39.694632 102.444909,40.0284235 C102.128685,40.3622149 101.724628,40.5291081 101.232725,40.5291081 L96.3839888,40.5291081 C94.8380073,40.5291081 93.3798875,40.2041055 92.0095857,39.5540906 C90.6392839,38.9040756 89.4358959,38.0169064 88.3993855,36.8925562 C87.3628752,35.768206 86.5371929,34.4681956 85.9223139,32.992486 C85.3074349,31.5167763 85,29.9532503 85,28.301861 C85,25.5963933 85.7554115,23.1544819 87.266257,20.9760534 C88.7771026,18.7976249 90.7095505,17.3395051 93.0636587,16.6016503 C93.2042025,14.2475421 93.7224499,12.0603624 94.6184164,10.0400456 C95.514383,8.0197289 96.7089871,6.26295807 98.2022647,4.76968048 C99.6955423,3.27640288 101.452313,2.10815028 103.47263,1.26488764 C105.492947,0.421624997 107.732829,0 110.192346,0 C112.089686,0 113.82889,0.237164061 115.410007,0.711499298 C116.991124,1.18583453 118.414109,1.8621913 119.679003,2.74058989 C120.943897,3.61898847 122.033095,4.69061868 122.946629,5.95551264 C123.860164,7.22040661 124.615575,8.62582326 125.212886,10.1718048 Z M113.249157,23.611236 L119.468188,30.4627107 C119.71414,30.7086623 119.837114,30.9985295 119.837114,31.3323209 C119.837114,31.6661124 119.71414,31.9735473 119.468188,32.2546348 L119.046559,32.5181531 C118.835743,32.7641047 118.563444,32.8607271 118.229652,32.8080232 C117.895861,32.7553193 117.605994,32.6059937 117.360042,32.3600421 L113.670787,28.2491573 L113.670787,45.2197331 C113.670787,45.7116364 113.503893,46.1156936 113.170102,46.4319171 C112.83631,46.7481406 112.441037,46.90625 111.98427,46.90625 C111.492366,46.90625 111.088309,46.7481406 110.772086,46.4319171 C110.455862,46.1156936 110.297753,45.7116364 110.297753,45.2197331 L110.297753,28.2491573 L106.713904,32.2546348 C106.467953,32.5005864 106.178086,32.649912 105.844294,32.7026159 C105.510503,32.7553198 105.220636,32.6586974 104.974684,32.4127458 L104.553055,32.1492275 C104.307103,31.86814 104.184129,31.5607051 104.184129,31.2269136 C104.184129,30.8931222 104.307103,30.603255 104.553055,30.3573034 L110.666678,23.611236 L110.666678,23.5585323 L111.088308,23.1369031 C111.193715,22.9963593 111.325473,22.8997369 111.483585,22.847033 C111.641697,22.7943291 111.791022,22.7679775 111.931566,22.7679775 C112.107246,22.7679775 112.265355,22.7943291 112.405899,22.847033 C112.546443,22.8997369 112.686984,22.9963593 112.827528,23.1369031 L113.249157,23.5585323 L113.249157,23.611236 Z\"><\/path><\/g><\/g><\/g><\/svg><\/div><div class=\"jfUpload-text\"><div class=\"jfUpload-heading forDesktop\">Drag and drop files here<\/div><div class=\"jfUpload-heading forMobile\">Select files to upload<\/div><div class=\"jfUpload-subheading\" style=\"display:\"><span><span class=\"maxFileSize\">Max. file size<\/span>: 10.6MB<\/span><\/div><\/div><\/div><div class=\"jfUpload-button-container\"><label class=\"jfUpload-button\" aria-hidden=\"true\" tabindex=\"0\" for=\"input_11\">Browse Files<\/label><\/div><\/div><div class=\"jfUpload-files-container\"><input type=\"file\" id=\"input_11\" name=\"q11_upperTeeth[]\" multiple=\"\" class=\"form-upload-multiple validate[required]\" 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c0.779,0,1.518-0.297,2.079-0.837C56.255,54.982,56.293,53.08,55.146,51.887z M23.984,6c9.374,0,17,7.626,17,17s-7.626,17-17,17  s-17-7.626-17-17S14.61,6,23.984,6z\"><\/path><\/svg><\/span><\/button><img loading=\"lazy\" alt=\"\" class=\"form-image jfImage isWide\" src=\"https:\/\/www.jotform.com\/uploads\/Gladwin_James\/form_files\/bottom.600fffb8725e53.87550427.jpg\" height=\"192px\" width=\"256px\" data-component=\"image\"\/><\/div><\/div><\/div><\/div><\/div><div class=\"jfCard-actions\"><button style=\"display:block\" type=\"button\" class=\"jfInput-button forPrev u-left\" data-component=\"button\" aria-label=\"Previous\" data-testid=\"previousButton_15\">Previous<\/button><button style=\"display:block\" type=\"button\" class=\"jfInput-button forNext u-right\" data-component=\"button\" aria-label=\"Next\" data-testid=\"nextButton_15\">Next<\/button><button style=\"display:none\" type=\"submit\" class=\"jfInput-button forSubmit form-submit-button u-right\" data-component=\"button\" 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