{"id":330,"date":"2022-06-27T17:53:57","date_gmt":"2022-06-27T15:53:57","guid":{"rendered":"https:\/\/assic.whitelabelbox.co.za\/health-professionals\/?page_id=330"},"modified":"2023-05-21T11:25:21","modified_gmt":"2023-05-21T09:25:21","slug":"register-your-practice","status":"publish","type":"page","link":"https:\/\/www.assic-health.com\/health-professionals\/register-your-practice\/","title":{"rendered":"Register Your Practice"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row full_width=&#8221;stretch_row&#8221; css=&#8221;.vc_custom_1656345775314{padding-top: 0px !important;padding-bottom: 0px !important;}&#8221;][vc_column]\n\t\t\t<!-- START Register Your Practice Slider REVOLUTION SLIDER 6.7.12 --><p class=\"rs-p-wp-fix\"><\/p>\n\t\t\t<rs-module-wrap id=\"rev_slider_6_1_wrapper\" data-source=\"gallery\" style=\"visibility:hidden;background:transparent;padding:0;margin:0px auto;margin-top:0;margin-bottom:0;\">\n\t\t\t\t<rs-module id=\"rev_slider_6_1\" style=\"\" data-version=\"6.7.12\">\n\t\t\t\t\t<rs-slides style=\"overflow: hidden; position: absolute;\">\n\t\t\t\t\t\t<rs-slide style=\"position: absolute;\" data-key=\"rs-12\" data-title=\"Slide\" data-duration=\"7000ms\" data-anim=\"adpr:false;ms:10;\" data-in=\"o:1;\" data-out=\"a:false;\">\n\t\t\t\t\t\t\t<img decoding=\"async\" src=\"\/\/www.assic-health.com\/health-professionals\/wp-content\/plugins\/revslider\/sr6\/assets\/assets\/dummy.png\" alt=\"register your practice on assic\" title=\"register your practice on assic\" width=\"1920\" height=\"1280\" class=\"rev-slidebg tp-rs-img rs-lazyload\" data-lazyload=\"\/\/www.assic-health.com\/health-professionals\/wp-content\/uploads\/sites\/4\/register-your-practice.jpg\" data-bg=\"p:0% 35%;\" data-no-retina>\n<!--\n\t\t\t\t\t\t\t--><rs-layer\n\t\t\t\t\t\t\t\tid=\"slider-6-slide-12-layer-0\" \n\t\t\t\t\t\t\t\tdata-type=\"text\"\n\t\t\t\t\t\t\t\tdata-rsp_ch=\"on\"\n\t\t\t\t\t\t\t\tdata-xy=\"x:l,l,l,c;xo:350px,96px,22px,0;y:m;yo:-110px,-80px,-85px,0;\"\n\t\t\t\t\t\t\t\tdata-text=\"w:normal;s:50,40,35,30;l:50,40,35,30;a:left,left,left,center;\"\n\t\t\t\t\t\t\t\tdata-dim=\"w:957px,510px,387px,95%;\"\n\t\t\t\t\t\t\t\tdata-frame_0=\"y:-50,-26,-19,-11;\"\n\t\t\t\t\t\t\t\tdata-frame_1=\"sp:1000;\"\n\t\t\t\t\t\t\t\tdata-frame_999=\"o:0;st:w;\"\n\t\t\t\t\t\t\t\tstyle=\"z-index:11;font-family:'Poppins';\"\n\t\t\t\t\t\t\t>Register Your <strong>Practice<\/strong> \n\t\t\t\t\t\t\t<\/rs-layer><!--\n\n\t\t\t\t\t\t\t--><rs-layer\n\t\t\t\t\t\t\t\tid=\"slider-6-slide-12-layer-1\" \n\t\t\t\t\t\t\t\tdata-type=\"text\"\n\t\t\t\t\t\t\t\tdata-rsp_ch=\"on\"\n\t\t\t\t\t\t\t\tdata-xy=\"xo:350px,96px,22px,13px;y:m;\"\n\t\t\t\t\t\t\t\tdata-text=\"w:normal;s:18,15,14,13;l:28,25,24,23;\"\n\t\t\t\t\t\t\t\tdata-dim=\"w:543px,396px,373px,230px;\"\n\t\t\t\t\t\t\t\tdata-vbility=\"t,t,t,f\"\n\t\t\t\t\t\t\t\tdata-frame_0=\"x:-50,-26,-19,-11;\"\n\t\t\t\t\t\t\t\tdata-frame_1=\"st:500;sp:1000;\"\n\t\t\t\t\t\t\t\tdata-frame_999=\"o:0;st:w;\"\n\t\t\t\t\t\t\t\tstyle=\"z-index:10;font-family:'Roboto';\"\n\t\t\t\t\t\t\t>Register your practice on the ASSIC website and get additional access for FREE to our education platform. \n\t\t\t\t\t\t\t<\/rs-layer><!--\n\n\t\t\t\t\t\t\t--><rs-layer\n\t\t\t\t\t\t\t\tid=\"slider-6-slide-12-layer-3\" 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window.RS_MODULES.checkMinimal()}\n\t\t\t\t<\/script>\n\t\t\t<\/rs-module-wrap>\n\t\t\t<!-- END REVOLUTION SLIDER -->\n[\/vc_column][\/vc_row][vc_row][vc_column]<div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-338\"><form id=\"wpforms-form-338\" class=\"wpforms-validate wpforms-form\" data-formid=\"338\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/health-professionals\/wp-json\/wp\/v2\/pages\/330?wpforms_form_id=338\" data-token=\"72c2d487cd42908b7be101b5e3fec324\" data-token-time=\"1734787537\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-338-field_4-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"4\"><h3 id=\"wpforms-338-field_4\" aria-errormessage=\"wpforms-338-field_4-error\">Personal Information<\/h3><\/div><div id=\"wpforms-338-field_0-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"0\"><label class=\"wpforms-field-label\" for=\"wpforms-338-field_0\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-338-field_0\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][0]\" aria-errormessage=\"wpforms-338-field_0-error\" required><\/div><div id=\"wpforms-338-field_1-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-338-field_1\">Surname <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-338-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" aria-errormessage=\"wpforms-338-field_1-error\" required><\/div><div id=\"wpforms-338-field_13-container\" class=\"wpforms-field wpforms-field-divider form-space\" data-field-id=\"13\"><h3 id=\"wpforms-338-field_13\" aria-errormessage=\"wpforms-338-field_13-error\">Contact Details<\/h3><\/div><div id=\"wpforms-338-field_2-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-half wpforms-first\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-338-field_2\">Phone number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-338-field_2\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][2]\" placeholder=\" \" aria-label=\"Phone number\" aria-errormessage=\"wpforms-338-field_2-error\" required><\/div><div id=\"wpforms-338-field_3-container\" class=\"wpforms-field wpforms-field-email wpforms-one-half\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-338-field_3\">Email address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-338-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" spellcheck=\"false\" aria-errormessage=\"wpforms-338-field_3-error\" required><\/div><div id=\"wpforms-338-field_5-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"5\"><fieldset><legend class=\"wpforms-field-label\">Practice address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-338-field_5\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][5][address1]\" aria-errormessage=\"wpforms-338-field_5-error\" required><label for=\"wpforms-338-field_5\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-338-field_5-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][5][address2]\" aria-errormessage=\"wpforms-338-field_5-address2-error\" ><label for=\"wpforms-338-field_5-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-338-field_5-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][5][city]\" aria-errormessage=\"wpforms-338-field_5-city-error\" required><label for=\"wpforms-338-field_5-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-338-field_5-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][5][state]\" aria-errormessage=\"wpforms-338-field_5-state-error\" required><label for=\"wpforms-338-field_5-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-338-field_5-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][5][postal]\" aria-errormessage=\"wpforms-338-field_5-postal-error\" required><label for=\"wpforms-338-field_5-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-338-field_5-country\" class=\"wpforms-field-address-country wpforms-field-required\" name=\"wpforms[fields][5][country]\" value=\"South Africa\" aria-errormessage=\"wpforms-338-field_5-country-error\" required><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\"  selected='selected'>South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-338-field_5-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-338-field_6-container\" class=\"wpforms-field wpforms-field-url\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-338-field_6\">Website \/ URL<\/label><input type=\"url\" id=\"wpforms-338-field_6\" class=\"wpforms-field-medium\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-338-field_6-error\" ><\/div><div id=\"wpforms-338-field_7-container\" class=\"wpforms-field wpforms-field-divider form-space\" data-field-id=\"7\"><h3 id=\"wpforms-338-field_7\" aria-errormessage=\"wpforms-338-field_7-error\">Education<\/h3><\/div><div id=\"wpforms-338-field_10-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-classic\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-338-field_10\">Title <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-338-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Please select<\/option><option value=\"Ms\" >Ms<\/option><option value=\"Mrs\" >Mrs<\/option><option value=\"Mr\" >Mr<\/option><option value=\"Dr\" >Dr<\/option><option value=\"Prof\" >Prof<\/option><\/select><\/div><div id=\"wpforms-338-field_8-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-338-field_8\">Speciality <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-338-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" aria-errormessage=\"wpforms-338-field_8-error\" required><\/div><div id=\"wpforms-338-field_11-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-338-field_11\">Qualifications <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-338-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-338-field_11-error\" required><\/textarea><\/div><div id=\"wpforms-338-field_12-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-338-field_12\">Interests \/ Areas of Specialization <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-338-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-338-field_12-error\" required><\/textarea><\/div><div id=\"wpforms-338-field_14-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-338-field_14\">Upload Profile Picture <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader\"\n\t\tdata-field-id=\"14\"\n\t\tdata-form-id=\"338\"\n\t\tdata-input-name=\"wpforms_338_14\"\n\t\tdata-extensions=\"png,jpeg,jpg,pdf\"\n\t\tdata-max-size=\"5242880\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"33554432\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg viewBox=\"0 0 1024 1024\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M885.2 446.3l-.2-.8-112.2-285.1c-5-16.1-19.9-27.2-36.8-27.2H281.2c-17 0-32.1 11.3-36.9 27.6L139.4 443l-.3.7-.2.8c-1.3 4.9-1.7 9.9-1 14.8-.1 1.6-.2 3.2-.2 4.8V830a60.9 60.9 0 0 0 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high quality and professional!\r\n<br\/>\r\n<br\/>\r\n<strong>File size: <\/strong>not more than 5MB<br\/>\r\n<strong>Allowed file types:<\/strong> PNG, JPEG, JPG, PDF<\/div><\/div><div id=\"wpforms-338-field_15-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-338-field_15\">Upload Qualifications <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader\"\n\t\tdata-field-id=\"15\"\n\t\tdata-form-id=\"338\"\n\t\tdata-input-name=\"wpforms_338_15\"\n\t\tdata-extensions=\"png,jpeg,jpg,pdf\"\n\t\tdata-max-size=\"5242880\"\n\t\tdata-max-file-number=\"20\"\n\t\tdata-post-max-size=\"33554432\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg viewBox=\"0 0 1024 1024\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M885.2 446.3l-.2-.8-112.2-285.1c-5-16.1-19.9-27.2-36.8-27.2H281.2c-17 0-32.1 11.3-36.9 27.6L139.4 443l-.3.7-.2.8c-1.3 4.9-1.7 9.9-1 14.8-.1 1.6-.2 3.2-.2 4.8V830a60.9 60.9 0 0 0 60.8 60.8h627.2c33.5 0 60.8-27.3 60.9-60.8V464.1c0-1.3 0-2.6-.1-3.7.4-4.9 0-9.6-1.3-14.1zm-295.8-43l-.3 15.7c-.8 44.9-31.8 75.1-77.1 75.1-22.1 0-41.1-7.1-54.8-20.6S436 441.2 435.6 419l-.3-15.7H229.5L309 210h399.2l81.7 193.3H589.4zm-375 76.8h157.3c24.3 57.1 76 90.8 140.4 90.8 33.7 0 65-9.4 90.3-27.2 22.2-15.6 39.5-37.4 50.7-63.6h156.5V814H214.4V480.1z\"><\/path>\n\t\t<\/svg>\n\t\t<span class=\"modern-title\">Click or drag files to this area to upload.<\/span>\n\n\t\t\t\t\t<span class=\"modern-hint\">You can upload up to 20 files.<\/span>\n\t\t\t<\/div>\n<\/div>\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-338-field_15\"\n\t\tname=\"wpforms_338_15\" required\t\tvalue=\"\">\n<div id=\"wpforms-338-field_15-description\" class=\"wpforms-field-description\"><strong>File size: <\/strong>not more than 5MB<br\/>\r\n<strong>Allowed file types:<\/strong> PNG, JPEG, JPG, PDF<\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha wpforms-is-recaptcha-type-v3\" ><input type=\"hidden\" name=\"wpforms[recaptcha]\" value=\"\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"338\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input 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