<div class="vc_row wpb_row vc_row-fluid vc_row_105458275"><div class="wpb_column vc_column_container vc_col-sm-12 vc_column_788990460"><div class="vc_column-inner "><div class="wpb_wrapper"><script type="text/javascript">var gform;gform||(document.addEventListener("gform_main_scripts_loaded",function(){gform.scriptsLoaded=!0}),window.addEventListener("DOMContentLoaded",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener("DOMContentLoaded",o):document.addEventListener("gform_main_scripts_loaded",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook("action",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook("filter",o,n,r,t)},doAction:function(o){gform.doHook("action",o,arguments)},applyFilters:function(o){return gform.doHook("filter",o,arguments)},removeAction:function(o,n){gform.removeHook("action",o,n)},removeFilter:function(o,n,r){gform.removeHook("filter",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+"_"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){"function"!=typeof(t=o.callable)&&(t=window[t]),"action"==n?t.apply(null,r):r[0]=t.apply(null,r)})),"filter"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});</script>
<div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_2' ><form method='post' enctype='multipart/form-data' id='gform_2' action='/wellness/' ><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LeXyoAeAAAAAFOxnJFUg_KPHsXsfaPEjzH4rjrL' data-tabindex='0'><input id="input_3340c8db712e9b7a8f6541e967fab25b" class="gfield_recaptcha_response" type="hidden" name="input_3340c8db712e9b7a8f6541e967fab25b" value=""/></div>
<input type='hidden' class='gforms-pum' value='{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}' />
<div class='gform_body gform-body'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'><li id="field_2_8" class="gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_2_8"><label class='gfield_label' for='input_2_8' >First and last name</label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_2_8' type='text' value='' class='large' aria-invalid="false" /> </div></li><li id="field_2_2" class="gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_2_2"><label class='gfield_label' for='input_2_2' >Phone</label><div class='ginput_container ginput_container_phone'><input name='input_2' id='input_2_2' type='text' value='' class='large' aria-invalid="false" /></div></li><li id="field_2_3" class="gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_2_3"><label class='gfield_label' for='input_2_3' >Email</label><div class='ginput_container ginput_container_email'>
<input name='input_3' id='input_2_3' type='text' value='' class='large' aria-invalid="false" />
</div></li><li id="field_2_6" class="gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_2_6"><label class='gfield_label' >Gender</label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_6'>
<li class='gchoice gchoice_2_6_0'>
<input name='input_6' type='radio' value='Male' id='choice_2_6_0' />
<label for='choice_2_6_0' id='label_2_6_0'>Male</label>
</li>
<li class='gchoice gchoice_2_6_1'>
<input name='input_6' type='radio' value='Female' id='choice_2_6_1' />
<label for='choice_2_6_1' id='label_2_6_1'>Female</label>
</li>
<li class='gchoice gchoice_2_6_2'>
<input name='input_6' type='radio' value='Other' id='choice_2_6_2' />
<label for='choice_2_6_2' id='label_2_6_2'>Other</label>
</li></ul></div></li><li id="field_2_5" class="gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_2_5"><label class='gfield_label' >Marital status</label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_5'>
<li class='gchoice gchoice_2_5_0'>
<input name='input_5' type='radio' value='Single' id='choice_2_5_0' />
<label for='choice_2_5_0' id='label_2_5_0'>Single</label>
</li>
<li class='gchoice gchoice_2_5_1'>
<input name='input_5' type='radio' value='Married' id='choice_2_5_1' />
<label for='choice_2_5_1' id='label_2_5_1'>Married</label>
</li>
<li class='gchoice gchoice_2_5_2'>
<input name='input_5' type='radio' value='Partner' id='choice_2_5_2' />
<label for='choice_2_5_2' id='label_2_5_2'>Partner</label>
</li>
<li class='gchoice gchoice_2_5_3'>
<input name='input_5' type='radio' value='Divorced' id='choice_2_5_3' />
<label for='choice_2_5_3' id='label_2_5_3'>Divorced</label>
</li></ul></div></li><li id="field_2_7" class="gfield field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_2_7"><label class='gfield_label' for='input_2_7' >Reason for claim:</label><div class='ginput_container ginput_container_textarea'><textarea name='input_7' id='input_2_7' class='textarea medium' aria-invalid="false" rows='10' cols='50'></textarea></div></li><li id="field_2_9" class="gfield field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_2_9"><label class='gfield_label' for='input_2_9' >CAPTCHA</label><div id='input_2_9' class='ginput_container ginput_recaptcha' data-sitekey='6LcUyoAeAAAAAF6T1AdGLIHWcR6fgKXmIVKBK0lS' data-theme='light' data-tabindex='0' data-badge=''></div></li></ul></div>
<div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' value='Submit' onclick='if(window["gf_submitting_2"]){return false;} window["gf_submitting_2"]=true; ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_2"]){return false;} window["gf_submitting_2"]=true; jQuery("#gform_2").trigger("submit",[true]); }' />
<input type='hidden' class='gform_hidden' name='is_submit_2' value='1' />
<input type='hidden' class='gform_hidden' name='gform_submit' value='2' />
<input type='hidden' class='gform_hidden' name='gform_unique_id' value='' />
<input type='hidden' class='gform_hidden' name='state_2' value='WyJbXSIsIjdkN2ZjZWMzYTFkYmY4MGI0OThlNzQwYzgzNWRhNTQ1Il0=' />
<input type='hidden' class='gform_hidden' name='gform_target_page_number_2' id='gform_target_page_number_2' value='0' />
<input type='hidden' class='gform_hidden' name='gform_source_page_number_2' id='gform_source_page_number_2' value='1' />
<input type='hidden' name='gform_field_values' value='' />
</div>
</form>
</div><style type="text/css"> .vc_column_788990460:not(.vc_parallax):not(.jarallax) { overflow: center!important; position: relative; }</style></div></div></div><style type="text/css"> .vc_row_105458275:not(.vc_parallax) { overflow: center!important; position: relative; }</style></div>
×
