{"id":10,"date":"2013-05-29T13:57:29","date_gmt":"2013-05-29T12:57:29","guid":{"rendered":"http:\/\/claddaghsurgery.ie\/?page_id=10"},"modified":"2024-05-13T09:46:37","modified_gmt":"2024-05-13T08:46:37","slug":"cert-extension-request","status":"publish","type":"page","link":"https:\/\/claddaghsurgery.ie\/cert-extension-request\/","title":{"rendered":"Cert Extension request"},"content":{"rendered":"<div data-uniq='6648c139f08fe' class='uniq-6648c139f08fe formcraft-css form-live align-left'><style type='text\/css' scoped='scoped'>#Content input[type=\"text\"], #Content input[type=\"password\"], #Content input[type=\"email\"], #Content textarea, #Content select {\n    font-size: 18px;\n    color: #000;\n}\n\n#Content button {\n    padding: 19px 21px;\n    font-size: 20px;\n}<\/style><script> window.formcraftLogic = window.formcraftLogic || {}; window.formcraftLogic[5] = [[[[\"field26\",\"equal_to\",\"Doctor's Note Extension\"]],[[\"show_fields\",\"field33,field27,field28\"]],\"and\"],[[[\"field26\",\"equal_to\",\"Social Welfare Cert Extension\"]],[[\"show_fields\",\"field34,field31,field32\"]],\"and\"],[[[\"field26\",\"equal_to\",\"Both - Doctor's Note & Social Welfare Cert Extension\"]],[[\"show_fields\",\"field33,field27,field28,field34,field31,field32\"]],\"and\"]]; <\/script><div class=\"fc-pagination-cover fc-pagination-1\">\n\t\t\t\t<div class=\"fc-pagination width-100\">\n\t\t\t\t\t<!-- ngRepeat: page in Builder.FormElements track by $index --><div class=\"pagination-trigger \" data-index=\"0\">\n\t\t\t\t\t\t<span class=\"page-number\"><span >1<\/span><\/span>\n\t\t\t\t\t\t<span class=\"page-name \"><\/span>\n\t\t\t\t\t\t\n\t\t\t\t\t<\/div><!-- end ngRepeat: page in Builder.FormElements track by $index -->\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t<style scoped=\"scoped\" >\n\t\t\t@media (max-width : 480px) {\n\t\t\t\t.fc_modal-dialog-5 .fc-pagination-cover .fc-pagination\n\t\t\t\t{\n\t\t\t\t\tbackground-color: #fdf0dc !important;\n\t\t\t\t}\n\t\t\t}\n\t\t\t\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .submit-cover .submit-button,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .fileupload-cover .button-file,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover .button,\n\t\t\t.formcraft-datepicker .ui-datepicker-header,\n\t\t\t.formcraft-datepicker .ui-datepicker-title\n\t\t\t{\n\t\t\t\tbackground: #f33c3f;\n\t\t\t\tcolor: #fff;\n\t\t\t}\n\t\t\t.formcraft-datepicker td .ui-state-active,\n\t\t\t.formcraft-datepicker td .ui-state-hover,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbackground: #f33c3f;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-header,\n\t\t\t.formcraft-css .fc-form .field-cover>div.full hr\n\t\t\t{\n\t\t\t\tborder-color: #d53437;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-prev:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-next:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker select.ui-datepicker-month:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker select.ui-datepicker-year:hover\n\t\t\t{\n\t\t\t\tbackground-color: #d53437;\n\t\t\t}\n\t\t\t.formcraft-css .fc-pagination>div.active .page-number,\n\t\t\t.formcraft-css .form-cover-builder .fc-pagination>div:first-child .page-number\n\t\t\t{\n\t\t\t\tbackground-color: #f33c3f;\n\t\t\t\tcolor: #fff;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker table.ui-datepicker-calendar th,\n\t\t\t#ui-datepicker-div.formcraft-datepicker table.ui-datepicker-calendar td.ui-datepicker-today a,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .star-cover label,\n\t\t\thtml .formcraft-css .fc-form.label-floating .form-element .field-cover.has-focus>span,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .customText-cover a,\n\t\t\t.formcraft-css .prev-next>div span:hover\n\t\t\t{\n\t\t\t\tcolor: #f33c3f;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .customText-cover a:hover\n\t\t\t{\n\t\t\t\tcolor: #d53437;\n\t\t\t}\n\t\t\thtml .formcraft-css .fc-form.fc-form-5.label-floating .form-element .field-cover > span\n\t\t\t{\n\t\t\t\tcolor: #666666;\n\t\t\t}\n\t\t\thtml .formcraft-css .fc-form .final-success .final-success-check {\n\t\t\t\tborder: 2px solid #666666;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover textarea,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover .time-fields-cover,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover .awesomplete ul\n\t\t\t{\n\t\t\t\tcolor: #777;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"radio\"],\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"checkbox\"],\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover textarea\n\t\t\t{\n\t\t\t\tbackground-color: #fafafa;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"radio\"]:checked,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"checkbox\"]:checked {\n\t\t\t\tborder-color: #d53437;\n\t\t\t\tbackground: #f33c3f;\t\t\t\t\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .star-cover label .star\n\t\t\t{\n\t\t\t\ttext-shadow: 0px 1px 0px #d53437;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbox-shadow: 0px 1px 1px #d53437 inset;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .fileupload-cover .button-file\n\t\t\t{\n\t\t\t\tborder-color: #d53437;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .form-element-html input[type=\"password\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .form-element-html input[type=\"email\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .form-element-html input[type=\"tel\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .form-element-html input[type=\"text\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .form-element-html textarea:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .form-element-html select:focus\n\t\t\t{\n\t\t\t\tborder-color: #f33c3f;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .form-element-html .field-cover .is-read-only:focus {\n\t\t\t\tborder-color: #ccc;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5\t\t\t{\n\t\t\t\tfont-family: Roboto;\n\t\t\t}\n\t\t\t@media (max-width : 480px) {\n\t\t\t\thtml .dedicated-page,\n\t\t\t\thtml .dedicated-page .formcraft-css .fc-pagination > div.active\n\t\t\t\t{\n\t\t\t\t\tbackground: #fdf0dc;\n\t\t\t\t}\n\t\t\t}\n\t\t<\/style>\n\t\t<div class=\"form-cover\">\n\t\t\t<form data-auto-scroll=\"\" data-no-message-redirect=\"\" data-thousand=\"\" data-decimal=\".\" data-delay=\"\" data-id=\"5\" class=\"fc-form fc-form-5 align- fc-temp-class save-form- label-floating field-border-visible frame-hidden dont-submit-hidden-true remove-asterisk-true icons-hide-true field-alignment-center disable-enter-true\" style=\"width: 600px; color: #666666; font-size: 135%; background: #fdf0dc\">\n\t\t\t\t<!-- ngRepeat: page in Builder.FormElements track by $index --><div class=\"form-page form-page-0\" data-index=\"0\">\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"form-page-content      ng-not-empty\">\n\t\t\t\t\t\t<div data-identifier=\"field16\" data-index=\"0\" style=\"width: 80%\" class=\" form-element form-element-field16 options-false form-element-0 default-false form-element-type-heading is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div style=\"background-color:\" class=\"heading-cover field-cover \"><div style=\"text-align: center; font-size: 1.4em; padding-top: 30px; padding-bottom: ; color:\" class=\"bold-\"><span >Extension Request of Doctor's Note or Social Welfare Certificate<\/span><\/div><input type=\"hidden\" data-field-id=\"field16\" name=\"field16[]\" value=\"Extension Request of Doctor's Note or Social Welfare Certificate\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field1\" data-index=\"1\" style=\"width: 80%\" class=\" even form-element form-element-field1 options-false form-element-1 default-false form-element-type-oneLineText is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Name<\/span><\/span><span class=\"sub-label\"><span >your full name<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"false\" data-field-id=\"field1\" name=\"field1[]\" data-min-char=\"\" data-max-char=\"50\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-icon-user\">icon-user<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field22\" data-index=\"2\" style=\"width: 80%\" class=\" form-element form-element-field22 options-false form-element-2 default-false form-element-type-oneLineText is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Address<\/span><\/span><span class=\"sub-label\"><span >Enter your address<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"false\" data-field-id=\"field22\" name=\"field22[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"Enter your full address\"><i class=\"formcraft-icon formcraft-icon-type-icon-home\">icon-home<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field4\" data-index=\"3\" style=\"width: 80%\" class=\" even form-element form-element-field4 options-false form-element-3 default-false form-element-type-oneLineText is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Contact Number<\/span><\/span><span class=\"sub-label\"><span >Your phone number<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"false\" data-field-id=\"field4\" name=\"field4[]\" data-min-char=\"7\" data-max-char=\"15\" data-val-type=\"alphanumeric\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-icon-phone\">icon-phone<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field25\" data-index=\"4\" style=\"width: 80%\" class=\" form-element form-element-field25 options-false form-element-4 default-false form-element-type-oneLineText is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover  \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Date of Birth<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"DD\/MM\/YYYY\" make-read-only=\"false\" data-field-id=\"field25\" name=\"field25[]\" data-min-char=\"10\" data-max-char=\"10\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"00\/00\/0000\" data-mask-placeholder=\"DD\/MM\/YYYY\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field26\" data-index=\"5\" style=\"width: 80%\" class=\" even form-element form-element-field26 options-false form-element-5 default-false form-element-type-dropdown is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type- \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Request Type<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"true\" class=\"validation-lenient\" data-field-id=\"field26\" name=\"field26\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \">Select An Option<\/option><option value=\"Doctor's Note Extension\" class=\" \">Doctor's Note Extension<\/option><option value=\"Social Welfare Cert Extension\" class=\" \">Social Welfare Cert Extension<\/option><option value=\"Both - Doctor's Note &amp; Social Welfare Cert Extension\" class=\" \">Both - Doctor's Note &amp; Social Welfare Cert Extension<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field33\" data-index=\"6\" style=\"width: 80%\" class=\" form-element form-element-field33 options-false form-element-6 default-true form-element-type-heading is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div style=\"background-color:\" class=\"heading-cover field-cover \"><div style=\"text-align: left; font-size: 1.1999999999999997em; padding-top: ; padding-bottom: ; color:\" class=\"bold-\"><span >Doctor's Note Extension Dates<\/span><\/div><input type=\"hidden\" data-field-id=\"field33\" name=\"field33[]\" value=\"Doctor's Note Extension Dates\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field27\" data-index=\"7\" style=\"width: 80%\" class=\" even form-element form-element-field27 options-false form-element-7 default-true form-element-type-oneLineText is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover  \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Doctor's Note START DATE<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"DD\/MM\/YYYY\" make-read-only=\"false\" data-field-id=\"field27\" name=\"field27[]\" data-min-char=\"10\" data-max-char=\"10\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"00\/00\/0000\" data-mask-placeholder=\"DD\/MM\/YYYY\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field28\" data-index=\"8\" style=\"width: 80%\" class=\" form-element form-element-field28 options-false form-element-8 default-true form-element-type-oneLineText is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover  \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Doctor's Note END DATE<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"DD\/MM\/YYYY\" make-read-only=\"false\" data-field-id=\"field28\" name=\"field28[]\" data-min-char=\"10\" data-max-char=\"10\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"00\/00\/0000\" data-mask-placeholder=\"DD\/MM\/YYYY\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field34\" data-index=\"9\" style=\"width: 80%\" class=\" even form-element form-element-field34 options-false form-element-9 default-true form-element-type-heading is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div style=\"background-color:\" class=\"heading-cover field-cover \"><div style=\"text-align: left; font-size: 1.1999999999999997em; padding-top: ; padding-bottom: ; color:\" class=\"bold-\"><span >Social Welfare Cert Extension Dates<\/span><\/div><input type=\"hidden\" data-field-id=\"field34\" name=\"field34[]\" value=\"Social Welfare Cert Extension Dates\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field31\" data-index=\"10\" style=\"width: 80%\" class=\" form-element form-element-field31 options-false form-element-10 default-true form-element-type-oneLineText is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover  \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Welfare Cert START DATE<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"DD\/MM\/YYYY\" make-read-only=\"false\" data-field-id=\"field31\" name=\"field31[]\" data-min-char=\"10\" data-max-char=\"10\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"00\/00\/0000\" data-mask-placeholder=\"DD\/MM\/YYYY\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field32\" data-index=\"11\" style=\"width: 80%\" class=\" even form-element form-element-field32 options-false form-element-11 default-true form-element-type-oneLineText is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover  \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Welfare Cert END DATE<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"DD\/MM\/YYYY\" make-read-only=\"false\" data-field-id=\"field32\" name=\"field32[]\" data-min-char=\"10\" data-max-char=\"10\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"00\/00\/0000\" data-mask-placeholder=\"DD\/MM\/YYYY\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field29\" data-index=\"12\" style=\"width: 80%\" class=\" form-element form-element-field29 options-false form-element-12 default-false form-element-type-checkbox is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Confirmation<\/span><\/span><span class=\"sub-label\"><span >pick one!<\/span><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field29\" type=\"radio\" data-is-required=\"true\" name=\"field29[]\" value=\"I am looking to extend an existing doctor's note or social welfare certificate.\" class=\"validation-lenient\"><span><span >I am looking to extend an existing doctor's note or social welfare certificate.<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field30\" data-index=\"13\" style=\"width: 80%\" class=\" even form-element form-element-field30 options-false form-element-13 default-false form-element-type-checkbox is-required-true 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default-false form-element-type-submit is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"align-center wide-true submit-cover field-cover\"><button type=\"submit\" class=\"button submit-button\"><span class=\"text \">Submit<\/span><span class=\"spin-cover\"><i style=\"color:\" class=\"loading-icon icon-cog animate-spin\"><\/i><\/span><\/button><\/div><div class=\"submit-response \"><\/div><label ><input type=\"text\" class=\"required_field\" name=\"website\" autocomplete=\"maple-syrup-pot\"><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div><!-- end ngRepeat: page in Builder.FormElements track by $index -->\n\t\t\t<\/form>\n\t\t\t<div class=\"prev-next prev-next-1\" style=\"width: 600px; color: #666666; font-size: 135%; background: #fdf0dc\">\n\t\t\t\t<div>\n\t\t\t\t\t\n\t\t\t\t\t<span class=\"inactive page-prev \"><i 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