{"id":106,"date":"2021-10-25T17:04:24","date_gmt":"2021-10-25T17:04:24","guid":{"rendered":"https:\/\/lassustandartsen.nl\/?page_id=106"},"modified":"2023-03-15T09:40:38","modified_gmt":"2023-03-15T09:40:38","slug":"nieuwe-client","status":"publish","type":"page","link":"https:\/\/lassustandartsen.nl\/amsterdam\/en\/nieuwe-client\/","title":{"rendered":"New Client registration"},"content":{"rendered":"\n<p>Our practice is always open for new clients.<br>Call us directly for an appointment or fill in the registration form below.<\/p>\n\n\n\n<p>If you decide to become our patient, you will notice that a number of things proceed differently than you may have been used to.&nbsp;We reserve a full hour for your first appointment.&nbsp;During that time we would like to get to know you, and hear your dental wishes and complaints. We will also discuss your general health.<\/p>\n\n\n\n<p>A very extensive dental examination will take place, and x-rays made. You can bring the dental information and x-rays from your previous dentist along, or have it sent to us.&nbsp;After this examination, we will discuss the current condition of your teeth with you in detail. If your dental situation is a little more complex, we will set up a second appointment for this discussion.<br>No procedures will be performed during your first visit unless you have urgent complaints.<\/p>\n\n\n\n<p>Lassusstraat 9:&nbsp;<a href=../../../../../../_tel_0031204713137/_>+31 20 47 13 137<br><\/a>Keizersgracht 132:&nbsp;<a href=../../../../../../_tel_0031204221912/_>+31 20 42 21 912<\/a><br>Stadionplein 125:&nbsp;<a href=../../../../../../_tel_0031202104007/_>+31 20 21 04 007<\/a><\/p>\n\n\n\n<div style=\"height:64px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<h2 class=\"wp-block-heading\">REGISTRATION<\/h2>\n\n\n<!-- HTML Forms v1.4.0 - https:\/\/wordpress.org\/plugins\/html-forms\/ -->\n<form method=\"post\"  class=\"hf-form hf-form-2392 \" data-id=\"2392\" data-title=\"Registration\" data-slug=\"registration\" data-message-success=\"Thank you! We will be in touch soon.\" data-message-invalid-email=\"Sorry, that email address looks invalid.\" data-message-required-field-missing=\"Please fill in the required fields.\" data-message-error=\"Oops. An error occurred.\"><input type=\"hidden\" name=\"_hf_form_id\" value=\"2392\" \/><div style=\"display: none;\"><input type=\"text\" name=\"_hf_h2392\" value=\"\" \/><\/div><div class=\"hf-fields-wrap\"><div class=\"grid lg:grid-cols-2 gap-[30px] registration-form\">\r\n\r\n\t<div>\r\n\t\t<label for=\"first-name\" class=\"block mb-2\">First name (Required)<\/label>\r\n\t\t<input type=\"text\" name=\"first-name\" id=\"first-name\" placeholder=\"Enter your first name\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t<\/div>\r\n\t<div>\r\n\t\t<label for=\"last-name\" class=\"block mb-2\">Last name (Required)<\/label>\r\n\t\t<input type=\"text\" name=\"last-name\" id=\"last-name\" placeholder=\"Enter your last name\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t<\/div>\r\n\r\n\t<div>\r\n\t\t<label for=\"birth-date\" class=\"block mb-2\">Date of birth (Required)<\/label>\r\n\t\t<input type=\"date\" name=\"birth-date\" id=\"birth-date\" placeholder=\"Enter your birthdate\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t<\/div>\r\n\t<div>\r\n\t\t<label for=\"gender\" class=\"block mb-2\">Gender (Required)<\/label>\r\n\t\t<select type=\"date\" name=\"gender\" id=\"gender\" placeholder=\"Gender\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t<option value=\"\">Select<\/option>\t\r\n\t\t\t<option value=\"male\">Male<\/option>\r\n\t\t\t<option value=\"female\">Female<\/option>\r\n\t\t\t<option value=\"other\">Other<\/option>\r\n\t\t<\/select>\r\n\t<\/div>\r\n\r\n\t<div>\r\n\t\t<label for=\"phone\" class=\"block mb-2\">Phone number (Required)<\/label>\r\n\t\t<input type=\"tel\" name=\"phone\" id=\"phone\" placeholder=\"Enter your phone number\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t<\/div>\r\n\t<div>\r\n\t\t<label for=\"email\" class=\"block mb-2\">Email (Required)<\/label>\r\n\t\t<input type=\"email\" name=\"email\" id=\"email\" placeholder=\"Enter your email\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t<\/div>\r\n\r\n\t<div class=\"lg:col-span-2\">\r\n\t\t<label for=\"location\" class=\"block mb-2\">Location<\/label>\r\n\t\t<select type=\"date\" name=\"location\" id=\"location\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t<option value=\"\">Select<\/option>\t\r\n\t\t\t<option value=\"Lassusstraat\">Lassusstraat<\/option>\r\n\t\t\t<option value=\"Keizersgracht\">Keizersgracht<\/option>\r\n\t\t\t<option value=\"Stadionplein\">Stadionplein<\/option>\r\n      \t\t<\/select>\r\n\t<\/div>\r\n\r\n\t<div class=\"lg:col-span-2 grid\">\r\n\t\t<section class=\"mt-14 pt-14 border-t border-[#E5E5E5] child child-1\">\r\n\t\t\t<div class=\"grid lg:grid-cols-2 gap-[30px]\">\r\n\t\t\t\t<div class=\"lg:col-span-2 flex justify-between items-center\">\r\n\t\t\t\t\t<div class=\"text-xl uppercase font-title\">\r\n\t\t\t\t\t\t<p class=\"!mb-0\">family member (child)<\/p>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<div class=\"text-right\">\r\n\t\t\t\t\t\t<div class=\"removeChild cursor-pointer bg-primary text-white w-10 h-10 rounded-full inline-flex items-center justify-center transform hover:scale-105 transition duration-200\">\r\n\t\t\t\t\t\t\t<svg width=\"13\" height=\"13\" viewBox=\"0 0 13 13\" fill=\"none\" >\r\n\t\t\t\t\t\t\t\t<path d=\"M7.82812 6.5L12.6719 11.3438C12.7109 11.4219 12.75 11.5 12.75 11.5781C12.75 11.6562 12.7109 11.7344 12.6719 11.7734L11.7734 12.6719C11.6953 12.75 11.6172 12.75 11.5391 12.75C11.4609 12.75 11.3828 12.75 11.3438 12.6719L6.5 7.82812L1.65625 12.6719C1.57812 12.75 1.5 12.75 1.42188 12.75C1.34375 12.75 1.26562 12.75 1.22656 12.6719L0.328125 11.7734C0.25 11.7344 0.25 11.6562 0.25 11.5781C0.25 11.5 0.25 11.4219 0.328125 11.3438L5.17188 6.5L0.328125 1.65625C0.25 1.61719 0.25 1.53906 0.25 1.46094C0.25 1.38281 0.25 1.30469 0.328125 1.22656L1.22656 0.328125C1.26562 0.289062 1.34375 0.25 1.42188 0.25C1.5 0.25 1.57812 0.289062 1.65625 0.328125L6.5 5.17188L11.3438 0.328125C11.3828 0.289062 11.4609 0.25 11.5391 0.25C11.6172 0.25 11.6953 0.289062 11.7734 0.328125L12.6719 1.22656C12.7109 1.30469 12.75 1.38281 12.75 1.46094C12.75 1.53906 12.7109 1.61719 12.6719 1.65625L11.8516 2.47656L7.82812 6.5Z\" fill=\"currentColor\"\/>\r\n\t\t\t\t\t\t\t<\/svg>\r\n\t\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"first-name-child-1\" class=\"block mb-2\">First name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"first-name-child-1\" id=\"first-name-child-1\" placeholder=\"Enter your first name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"last-name-child-1\" class=\"block mb-2\">Last name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"last-name-child-1\" id=\"last-name-child-1\" placeholder=\"Enter your last name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"birth-date-child-1\" class=\"block mb-2\">Date of birth (Required)<\/label>\r\n\t\t\t\t\t<input type=\"date\" name=\"birth-date-child-1\" id=\"birth-date-child-1\" placeholder=\"Enter your birthdate\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"gender-child-1\" class=\"block mb-2\">Gender (Required)<\/label>\r\n\t\t\t\t\t<select type=\"date\" name=\"gender-child-1\" id=\"gender-child-1\" placeholder=\"Gender\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t\t\t<option value=\"\">Select<\/option>\t\r\n\t\t\t\t\t\t<option value=\"male\">Male<\/option>\r\n\t\t\t\t\t\t<option value=\"female\">Female<\/option>\r\n\t\t\t\t\t\t<option value=\"other\">Other<\/option>\r\n\t\t\t\t\t<\/select>\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t<\/div>\r\n\t\t<\/section>\r\n\r\n\t\t<section class=\"mt-14 pt-14 border-t border-[#E5E5E5] child child-2\">\r\n\t\t\t<div class=\"grid lg:grid-cols-2 gap-[30px]\">\r\n\t\t\t\t<div class=\"lg:col-span-2 flex justify-between items-center\">\r\n\t\t\t\t\t<div class=\"text-xl uppercase font-title\">\r\n\t\t\t\t\t\t<p class=\"!mb-0\">family member (child)<\/p>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<div class=\"text-right\">\r\n\t\t\t\t\t\t<div class=\"removeChild cursor-pointer bg-primary text-white w-10 h-10 rounded-full inline-flex items-center justify-center transform hover:scale-105 transition duration-200\">\r\n\t\t\t\t\t\t\t<svg width=\"13\" height=\"13\" viewBox=\"0 0 13 13\" fill=\"none\" >\r\n\t\t\t\t\t\t\t\t<path d=\"M7.82812 6.5L12.6719 11.3438C12.7109 11.4219 12.75 11.5 12.75 11.5781C12.75 11.6562 12.7109 11.7344 12.6719 11.7734L11.7734 12.6719C11.6953 12.75 11.6172 12.75 11.5391 12.75C11.4609 12.75 11.3828 12.75 11.3438 12.6719L6.5 7.82812L1.65625 12.6719C1.57812 12.75 1.5 12.75 1.42188 12.75C1.34375 12.75 1.26562 12.75 1.22656 12.6719L0.328125 11.7734C0.25 11.7344 0.25 11.6562 0.25 11.5781C0.25 11.5 0.25 11.4219 0.328125 11.3438L5.17188 6.5L0.328125 1.65625C0.25 1.61719 0.25 1.53906 0.25 1.46094C0.25 1.38281 0.25 1.30469 0.328125 1.22656L1.22656 0.328125C1.26562 0.289062 1.34375 0.25 1.42188 0.25C1.5 0.25 1.57812 0.289062 1.65625 0.328125L6.5 5.17188L11.3438 0.328125C11.3828 0.289062 11.4609 0.25 11.5391 0.25C11.6172 0.25 11.6953 0.289062 11.7734 0.328125L12.6719 1.22656C12.7109 1.30469 12.75 1.38281 12.75 1.46094C12.75 1.53906 12.7109 1.61719 12.6719 1.65625L11.8516 2.47656L7.82812 6.5Z\" fill=\"currentColor\"\/>\r\n\t\t\t\t\t\t\t<\/svg>\r\n\t\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"first-name-child-2\" class=\"block mb-2\">First name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"first-name-child-2\" id=\"first-name-child-2\" placeholder=\"Enter your first name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"last-name-child-2\" class=\"block mb-2\">Last name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"last-name-child-2\" id=\"last-name-child-2\" placeholder=\"Enter your last name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"birth-date-child-2\" class=\"block mb-2\">Date of birth (Required)<\/label>\r\n\t\t\t\t\t<input type=\"date\" name=\"birth-date-child-2\" id=\"birth-date-child-2\" placeholder=\"Enter your birthdate\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"gender-child-2\" class=\"block mb-2\">Gender (Required)<\/label>\r\n\t\t\t\t\t<select type=\"date\" name=\"gender-child-2\" id=\"gender-child-2\" placeholder=\"Gender\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t\t\t<option value=\"\">Select<\/option>\t\r\n\t\t\t\t\t\t<option value=\"male\">Male<\/option>\r\n\t\t\t\t\t\t<option value=\"female\">Female<\/option>\r\n\t\t\t\t\t\t<option value=\"other\">Other<\/option>\r\n\t\t\t\t\t<\/select>\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t<\/div>\r\n\t\t<\/section>\r\n\r\n\t\t<section class=\"mt-14 pt-14 border-t border-[#E5E5E5] child child-3\">\r\n\t\t\t<div class=\"grid lg:grid-cols-2 gap-[30px]\">\r\n\t\t\t\t<div class=\"lg:col-span-2 flex justify-between items-center\">\r\n\t\t\t\t\t<div class=\"text-xl uppercase font-title\">\r\n\t\t\t\t\t\t<p class=\"!mb-0\">family member (child)<\/p>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<div class=\"text-right\">\r\n\t\t\t\t\t\t<div class=\"removeChild cursor-pointer bg-primary text-white w-10 h-10 rounded-full inline-flex items-center justify-center transform hover:scale-105 transition duration-200\">\r\n\t\t\t\t\t\t\t<svg width=\"13\" height=\"13\" viewBox=\"0 0 13 13\" fill=\"none\" >\r\n\t\t\t\t\t\t\t\t<path d=\"M7.82812 6.5L12.6719 11.3438C12.7109 11.4219 12.75 11.5 12.75 11.5781C12.75 11.6562 12.7109 11.7344 12.6719 11.7734L11.7734 12.6719C11.6953 12.75 11.6172 12.75 11.5391 12.75C11.4609 12.75 11.3828 12.75 11.3438 12.6719L6.5 7.82812L1.65625 12.6719C1.57812 12.75 1.5 12.75 1.42188 12.75C1.34375 12.75 1.26562 12.75 1.22656 12.6719L0.328125 11.7734C0.25 11.7344 0.25 11.6562 0.25 11.5781C0.25 11.5 0.25 11.4219 0.328125 11.3438L5.17188 6.5L0.328125 1.65625C0.25 1.61719 0.25 1.53906 0.25 1.46094C0.25 1.38281 0.25 1.30469 0.328125 1.22656L1.22656 0.328125C1.26562 0.289062 1.34375 0.25 1.42188 0.25C1.5 0.25 1.57812 0.289062 1.65625 0.328125L6.5 5.17188L11.3438 0.328125C11.3828 0.289062 11.4609 0.25 11.5391 0.25C11.6172 0.25 11.6953 0.289062 11.7734 0.328125L12.6719 1.22656C12.7109 1.30469 12.75 1.38281 12.75 1.46094C12.75 1.53906 12.7109 1.61719 12.6719 1.65625L11.8516 2.47656L7.82812 6.5Z\" fill=\"currentColor\"\/>\r\n\t\t\t\t\t\t\t<\/svg>\r\n\t\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"first-name-child-3\" class=\"block mb-2\">First name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"first-name-child-3\" id=\"first-name-child-3\" placeholder=\"Enter your first name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"last-name-child-3\" class=\"block mb-2\">Last name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"last-name-child-3\" id=\"last-name-child-3\" placeholder=\"Enter your last name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"birth-date-child-3\" class=\"block mb-2\">Date of birth (Required)<\/label>\r\n\t\t\t\t\t<input type=\"date\" name=\"birth-date-child-3\" id=\"birth-date-child-3\" placeholder=\"Enter your birthdate\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"gender-child-3\" class=\"block mb-2\">Gender (Required)<\/label>\r\n\t\t\t\t\t<select type=\"date\" name=\"gender-child-3\" id=\"gender-child-3\" placeholder=\"Gender\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t\t\t<option value=\"\">Select<\/option>\t\r\n\t\t\t\t\t\t<option value=\"male\">Male<\/option>\r\n\t\t\t\t\t\t<option value=\"female\">Female<\/option>\r\n\t\t\t\t\t\t<option value=\"other\">Other<\/option>\r\n\t\t\t\t\t<\/select>\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t<\/div>\r\n\t\t<\/section>\r\n\r\n\t\t<section class=\"mt-14 pt-14 border-t border-[#E5E5E5] child child-4\">\r\n\t\t\t<div class=\"grid lg:grid-cols-2 gap-[30px]\">\r\n\t\t\t\t<div class=\"lg:col-span-2 flex justify-between items-center\">\r\n\t\t\t\t\t<div class=\"text-xl uppercase font-title\">\r\n\t\t\t\t\t\t<p class=\"!mb-0\">family member (child)<\/p>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<div class=\"text-right\">\r\n\t\t\t\t\t\t<div class=\"removeChild cursor-pointer bg-primary text-white w-10 h-10 rounded-full inline-flex items-center justify-center transform hover:scale-105 transition duration-200\">\r\n\t\t\t\t\t\t\t<svg width=\"13\" height=\"13\" viewBox=\"0 0 13 13\" fill=\"none\" >\r\n\t\t\t\t\t\t\t\t<path d=\"M7.82812 6.5L12.6719 11.3438C12.7109 11.4219 12.75 11.5 12.75 11.5781C12.75 11.6562 12.7109 11.7344 12.6719 11.7734L11.7734 12.6719C11.6953 12.75 11.6172 12.75 11.5391 12.75C11.4609 12.75 11.3828 12.75 11.3438 12.6719L6.5 7.82812L1.65625 12.6719C1.57812 12.75 1.5 12.75 1.42188 12.75C1.34375 12.75 1.26562 12.75 1.22656 12.6719L0.328125 11.7734C0.25 11.7344 0.25 11.6562 0.25 11.5781C0.25 11.5 0.25 11.4219 0.328125 11.3438L5.17188 6.5L0.328125 1.65625C0.25 1.61719 0.25 1.53906 0.25 1.46094C0.25 1.38281 0.25 1.30469 0.328125 1.22656L1.22656 0.328125C1.26562 0.289062 1.34375 0.25 1.42188 0.25C1.5 0.25 1.57812 0.289062 1.65625 0.328125L6.5 5.17188L11.3438 0.328125C11.3828 0.289062 11.4609 0.25 11.5391 0.25C11.6172 0.25 11.6953 0.289062 11.7734 0.328125L12.6719 1.22656C12.7109 1.30469 12.75 1.38281 12.75 1.46094C12.75 1.53906 12.7109 1.61719 12.6719 1.65625L11.8516 2.47656L7.82812 6.5Z\" fill=\"currentColor\"\/>\r\n\t\t\t\t\t\t\t<\/svg>\r\n\t\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"first-name-child-4\" class=\"block mb-2\">First name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"first-name-child-4\" id=\"first-name-child-4\" placeholder=\"Enter your first name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"last-name-child-4\" class=\"block mb-2\">Last name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"last-name-child-4\" id=\"last-name-child-4\" placeholder=\"Enter your last name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"birth-date-child-4\" class=\"block mb-2\">Date of birth (Required)<\/label>\r\n\t\t\t\t\t<input type=\"date\" name=\"birth-date-child-4\" id=\"birth-date-child-4\" placeholder=\"Enter your birthdate\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"gender-child-4\" class=\"block mb-2\">Gender (Required)<\/label>\r\n\t\t\t\t\t<select type=\"date\" name=\"gender-child-4\" id=\"gender-child-4\" placeholder=\"Gender\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t\t\t<option value=\"\">Select<\/option>\t\r\n\t\t\t\t\t\t<option value=\"male\">Male<\/option>\r\n\t\t\t\t\t\t<option value=\"female\">Female<\/option>\r\n\t\t\t\t\t\t<option value=\"other\">Other<\/option>\r\n\t\t\t\t\t<\/select>\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t<\/div>\r\n\t\t<\/section>\r\n\r\n\t\t<section class=\"mt-14 pt-14 border-t border-[#E5E5E5] child child-5\">\r\n\t\t\t<div class=\"grid lg:grid-cols-2 gap-[30px]\">\r\n\t\t\t\t<div class=\"lg:col-span-2 flex justify-between items-center\">\r\n\t\t\t\t\t<div class=\"text-xl uppercase font-title\">\r\n\t\t\t\t\t\t<p class=\"!mb-0\">family member (child)<\/p>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<div class=\"text-right\">\r\n\t\t\t\t\t\t<div class=\"removeChild cursor-pointer bg-primary text-white w-10 h-10 rounded-full inline-flex items-center justify-center transform hover:scale-105 transition duration-200\">\r\n\t\t\t\t\t\t\t<svg width=\"13\" height=\"13\" viewBox=\"0 0 13 13\" fill=\"none\" >\r\n\t\t\t\t\t\t\t\t<path d=\"M7.82812 6.5L12.6719 11.3438C12.7109 11.4219 12.75 11.5 12.75 11.5781C12.75 11.6562 12.7109 11.7344 12.6719 11.7734L11.7734 12.6719C11.6953 12.75 11.6172 12.75 11.5391 12.75C11.4609 12.75 11.3828 12.75 11.3438 12.6719L6.5 7.82812L1.65625 12.6719C1.57812 12.75 1.5 12.75 1.42188 12.75C1.34375 12.75 1.26562 12.75 1.22656 12.6719L0.328125 11.7734C0.25 11.7344 0.25 11.6562 0.25 11.5781C0.25 11.5 0.25 11.4219 0.328125 11.3438L5.17188 6.5L0.328125 1.65625C0.25 1.61719 0.25 1.53906 0.25 1.46094C0.25 1.38281 0.25 1.30469 0.328125 1.22656L1.22656 0.328125C1.26562 0.289062 1.34375 0.25 1.42188 0.25C1.5 0.25 1.57812 0.289062 1.65625 0.328125L6.5 5.17188L11.3438 0.328125C11.3828 0.289062 11.4609 0.25 11.5391 0.25C11.6172 0.25 11.6953 0.289062 11.7734 0.328125L12.6719 1.22656C12.7109 1.30469 12.75 1.38281 12.75 1.46094C12.75 1.53906 12.7109 1.61719 12.6719 1.65625L11.8516 2.47656L7.82812 6.5Z\" fill=\"currentColor\"\/>\r\n\t\t\t\t\t\t\t<\/svg>\r\n\t\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"first-name-child-5\" class=\"block mb-2\">First name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"first-name-child-5\" id=\"first-name-child-5\" placeholder=\"Enter your first name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"last-name-child-5\" class=\"block mb-2\">Last name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"last-name-child-5\" id=\"last-name-child-5\" placeholder=\"Enter your last name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"birth-date-child-5\" class=\"block mb-2\">Date of birth (Required)<\/label>\r\n\t\t\t\t\t<input type=\"date\" name=\"birth-date-child-5\" id=\"birth-date-child-5\" placeholder=\"Enter your birthdate\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"gender-child-5\" class=\"block mb-2\">Gender (Required)<\/label>\r\n\t\t\t\t\t<select type=\"date\" name=\"gender-child-5\" id=\"gender-child-5\" placeholder=\"Gender\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t\t\t<option value=\"\">Select<\/option>\t\r\n\t\t\t\t\t\t<option value=\"male\">Male<\/option>\r\n\t\t\t\t\t\t<option value=\"female\">Female<\/option>\r\n\t\t\t\t\t\t<option value=\"other\">Other<\/option>\r\n\t\t\t\t\t<\/select>\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t<\/div>\r\n\t\t<\/section>\r\n\r\n\t\t\r\n\t\t<section class=\"mt-14 pt-14 border-t border-[#E5E5E5] adult adult-1\">\r\n\t\t\t<div class=\"grid lg:grid-cols-2 gap-[30px]\">\r\n\t\t\t\t<div class=\"lg:col-span-2 flex justify-between items-center\">\r\n\t\t\t\t\t<div class=\"text-xl uppercase font-title\">\r\n\t\t\t\t\t\t<p class=\"!mb-0\">family member (adult)<\/p>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<div class=\"text-right\">\r\n\t\t\t\t\t\t<div class=\"removeAdult cursor-pointer bg-primary text-white w-10 h-10 rounded-full inline-flex items-center justify-center transform hover:scale-105 transition duration-200\">\r\n\t\t\t\t\t\t\t<svg width=\"13\" height=\"13\" viewBox=\"0 0 13 13\" fill=\"none\" >\r\n\t\t\t\t\t\t\t\t<path d=\"M7.82812 6.5L12.6719 11.3438C12.7109 11.4219 12.75 11.5 12.75 11.5781C12.75 11.6562 12.7109 11.7344 12.6719 11.7734L11.7734 12.6719C11.6953 12.75 11.6172 12.75 11.5391 12.75C11.4609 12.75 11.3828 12.75 11.3438 12.6719L6.5 7.82812L1.65625 12.6719C1.57812 12.75 1.5 12.75 1.42188 12.75C1.34375 12.75 1.26562 12.75 1.22656 12.6719L0.328125 11.7734C0.25 11.7344 0.25 11.6562 0.25 11.5781C0.25 11.5 0.25 11.4219 0.328125 11.3438L5.17188 6.5L0.328125 1.65625C0.25 1.61719 0.25 1.53906 0.25 1.46094C0.25 1.38281 0.25 1.30469 0.328125 1.22656L1.22656 0.328125C1.26562 0.289062 1.34375 0.25 1.42188 0.25C1.5 0.25 1.57812 0.289062 1.65625 0.328125L6.5 5.17188L11.3438 0.328125C11.3828 0.289062 11.4609 0.25 11.5391 0.25C11.6172 0.25 11.6953 0.289062 11.7734 0.328125L12.6719 1.22656C12.7109 1.30469 12.75 1.38281 12.75 1.46094C12.75 1.53906 12.7109 1.61719 12.6719 1.65625L11.8516 2.47656L7.82812 6.5Z\" fill=\"currentColor\"\/>\r\n\t\t\t\t\t\t\t<\/svg>\r\n\t\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"first-name-adult-1\" class=\"block mb-2\">First name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"first-name-adult-1\" id=\"first-name-adult-1\" placeholder=\"Enter your first name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"last-name-adult-1\" class=\"block mb-2\">Last name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"last-name-adult-1\" id=\"last-name-adult-1\" placeholder=\"Enter your last name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"birth-date-adult-1\" class=\"block mb-2\">Date of birth (Required)<\/label>\r\n\t\t\t\t\t<input type=\"date\" name=\"birth-date-adult-1\" id=\"birth-date-adult-1\" placeholder=\"Enter your birthdate\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"gender-adult-1\" class=\"block mb-2\">Gender (Required)<\/label>\r\n\t\t\t\t\t<select type=\"date\" name=\"gender-adult-1\" id=\"gender-adult-1\" placeholder=\"Gender\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t\t\t<option value=\"\">Select<\/option>\t\r\n\t\t\t\t\t\t<option value=\"male\">Male<\/option>\r\n\t\t\t\t\t\t<option value=\"female\">Female<\/option>\r\n\t\t\t\t\t\t<option value=\"other\">Other<\/option>\r\n\t\t\t\t\t<\/select>\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"phone-adult-1\" class=\"block mb-2\">Phone number (Required)<\/label>\r\n\t\t\t\t\t<input type=\"tel\" name=\"phone-adult-1\" id=\"phone-adult-1\" placeholder=\"Enter your phone number\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"email-adult-1\" class=\"block mb-2\">Email (Required)<\/label>\r\n\t\t\t\t\t<input type=\"email\" name=\"email-adult-1\" id=\"email-adult-1\" placeholder=\"Enter your email\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t<\/div>\r\n\t\t<\/section>\r\n\r\n\t\t<section class=\"mt-14 pt-14 border-t border-[#E5E5E5] adult adult-2\">\r\n\t\t\t<div class=\"grid lg:grid-cols-2 gap-[30px]\">\r\n\t\t\t\t<div class=\"lg:col-span-2 flex justify-between items-center\">\r\n\t\t\t\t\t<div class=\"text-xl uppercase font-title\">\r\n\t\t\t\t\t\t<p class=\"!mb-0\">family member (adult)<\/p>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<div class=\"text-right\">\r\n\t\t\t\t\t\t<div class=\"removeAdult cursor-pointer bg-primary text-white w-10 h-10 rounded-full inline-flex items-center justify-center transform hover:scale-105 transition duration-200\">\r\n\t\t\t\t\t\t\t<svg width=\"13\" height=\"13\" viewBox=\"0 0 13 13\" fill=\"none\" >\r\n\t\t\t\t\t\t\t\t<path d=\"M7.82812 6.5L12.6719 11.3438C12.7109 11.4219 12.75 11.5 12.75 11.5781C12.75 11.6562 12.7109 11.7344 12.6719 11.7734L11.7734 12.6719C11.6953 12.75 11.6172 12.75 11.5391 12.75C11.4609 12.75 11.3828 12.75 11.3438 12.6719L6.5 7.82812L1.65625 12.6719C1.57812 12.75 1.5 12.75 1.42188 12.75C1.34375 12.75 1.26562 12.75 1.22656 12.6719L0.328125 11.7734C0.25 11.7344 0.25 11.6562 0.25 11.5781C0.25 11.5 0.25 11.4219 0.328125 11.3438L5.17188 6.5L0.328125 1.65625C0.25 1.61719 0.25 1.53906 0.25 1.46094C0.25 1.38281 0.25 1.30469 0.328125 1.22656L1.22656 0.328125C1.26562 0.289062 1.34375 0.25 1.42188 0.25C1.5 0.25 1.57812 0.289062 1.65625 0.328125L6.5 5.17188L11.3438 0.328125C11.3828 0.289062 11.4609 0.25 11.5391 0.25C11.6172 0.25 11.6953 0.289062 11.7734 0.328125L12.6719 1.22656C12.7109 1.30469 12.75 1.38281 12.75 1.46094C12.75 1.53906 12.7109 1.61719 12.6719 1.65625L11.8516 2.47656L7.82812 6.5Z\" fill=\"currentColor\"\/>\r\n\t\t\t\t\t\t\t<\/svg>\r\n\t\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"first-name-adult-2\" class=\"block mb-2\">First name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"first-name-adult-2\" id=\"first-name-adult-2\" placeholder=\"Enter your first name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"last-name-adult-2\" class=\"block mb-2\">Last name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"last-name-adult-2\" id=\"last-name-adult-2\" placeholder=\"Enter your last name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"birth-date-adult-2\" class=\"block mb-2\">Date of birth (Required)<\/label>\r\n\t\t\t\t\t<input type=\"date\" name=\"birth-date-adult-2\" id=\"birth-date-adult-2\" placeholder=\"Enter your birthdate\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"gender-adult-2\" class=\"block mb-2\">Gender (Required)<\/label>\r\n\t\t\t\t\t<select type=\"date\" name=\"gender-adult-2\" id=\"gender-adult-2\" placeholder=\"Gender\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t\t\t<option value=\"\">Select<\/option>\t\r\n\t\t\t\t\t\t<option value=\"male\">Male<\/option>\r\n\t\t\t\t\t\t<option value=\"female\">Female<\/option>\r\n\t\t\t\t\t\t<option value=\"other\">Other<\/option>\r\n\t\t\t\t\t<\/select>\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"phone-adult-2\" class=\"block mb-2\">Phone number (Required)<\/label>\r\n\t\t\t\t\t<input type=\"tel\" name=\"phone-adult-2\" id=\"phone-adult-2\" placeholder=\"Enter your phone number\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"email-adult-2\" class=\"block mb-2\">Email (Required)<\/label>\r\n\t\t\t\t\t<input type=\"email\" name=\"email-adult-2\" id=\"email-adult-2\" placeholder=\"Enter your email\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t<\/div>\r\n\t\t<\/section>\r\n\r\n\t\t<section class=\"mt-14 pt-14 border-t border-[#E5E5E5] adult adult-3\">\r\n\t\t\t<div class=\"grid lg:grid-cols-2 gap-[30px]\">\r\n\t\t\t\t<div class=\"lg:col-span-2 flex justify-between items-center\">\r\n\t\t\t\t\t<div class=\"text-xl uppercase font-title\">\r\n\t\t\t\t\t\t<p class=\"!mb-0\">family member (adult)<\/p>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<div class=\"text-right\">\r\n\t\t\t\t\t\t<div class=\"removeAdult cursor-pointer bg-primary text-white w-10 h-10 rounded-full inline-flex items-center justify-center transform hover:scale-105 transition duration-200\">\r\n\t\t\t\t\t\t\t<svg width=\"13\" height=\"13\" viewBox=\"0 0 13 13\" fill=\"none\" >\r\n\t\t\t\t\t\t\t\t<path d=\"M7.82812 6.5L12.6719 11.3438C12.7109 11.4219 12.75 11.5 12.75 11.5781C12.75 11.6562 12.7109 11.7344 12.6719 11.7734L11.7734 12.6719C11.6953 12.75 11.6172 12.75 11.5391 12.75C11.4609 12.75 11.3828 12.75 11.3438 12.6719L6.5 7.82812L1.65625 12.6719C1.57812 12.75 1.5 12.75 1.42188 12.75C1.34375 12.75 1.26562 12.75 1.22656 12.6719L0.328125 11.7734C0.25 11.7344 0.25 11.6562 0.25 11.5781C0.25 11.5 0.25 11.4219 0.328125 11.3438L5.17188 6.5L0.328125 1.65625C0.25 1.61719 0.25 1.53906 0.25 1.46094C0.25 1.38281 0.25 1.30469 0.328125 1.22656L1.22656 0.328125C1.26562 0.289062 1.34375 0.25 1.42188 0.25C1.5 0.25 1.57812 0.289062 1.65625 0.328125L6.5 5.17188L11.3438 0.328125C11.3828 0.289062 11.4609 0.25 11.5391 0.25C11.6172 0.25 11.6953 0.289062 11.7734 0.328125L12.6719 1.22656C12.7109 1.30469 12.75 1.38281 12.75 1.46094C12.75 1.53906 12.7109 1.61719 12.6719 1.65625L11.8516 2.47656L7.82812 6.5Z\" fill=\"currentColor\"\/>\r\n\t\t\t\t\t\t\t<\/svg>\r\n\t\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"first-name-adult-3\" class=\"block mb-2\">First name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"first-name-adult-3\" id=\"first-name-adult-3\" placeholder=\"Enter your first name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"last-name-adult-3\" class=\"block mb-2\">Last name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"last-name-adult-3\" id=\"last-name-adult-3\" placeholder=\"Enter your last name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"birth-date-adult-3\" class=\"block mb-2\">Date of birth (Required)<\/label>\r\n\t\t\t\t\t<input type=\"date\" name=\"birth-date-adult-3\" id=\"birth-date-adult-3\" placeholder=\"Enter your birthdate\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"gender-adult-3\" class=\"block mb-2\">Gender (Required)<\/label>\r\n\t\t\t\t\t<select type=\"date\" name=\"gender-adult-3\" id=\"gender-adult-3\" placeholder=\"Gender\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t\t\t<option value=\"\">Select<\/option>\t\r\n\t\t\t\t\t\t<option value=\"male\">Male<\/option>\r\n\t\t\t\t\t\t<option value=\"female\">Female<\/option>\r\n\t\t\t\t\t\t<option value=\"other\">Other<\/option>\r\n\t\t\t\t\t<\/select>\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"phone-adult-3\" class=\"block mb-2\">Phone number (Required)<\/label>\r\n\t\t\t\t\t<input type=\"tel\" name=\"phone-adult-3\" id=\"phone-adult-3\" placeholder=\"Enter your phone number\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"email-adult-3\" class=\"block mb-2\">Email (Required)<\/label>\r\n\t\t\t\t\t<input type=\"email\" name=\"email-adult-3\" id=\"email-adult-3\" placeholder=\"Enter your email\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t<\/div>\r\n\t\t<\/section>\r\n\r\n\t\t<section class=\"mt-14 pt-14 border-t border-[#E5E5E5] adult adult-4\">\r\n\t\t\t<div class=\"grid lg:grid-cols-2 gap-[30px]\">\r\n\t\t\t\t<div class=\"lg:col-span-2 flex justify-between items-center\">\r\n\t\t\t\t\t<div class=\"text-xl uppercase font-title\">\r\n\t\t\t\t\t\t<p class=\"!mb-0\">family member (adult)<\/p>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<div class=\"text-right\">\r\n\t\t\t\t\t\t<div class=\"removeAdult cursor-pointer bg-primary text-white w-10 h-10 rounded-full inline-flex items-center justify-center transform hover:scale-105 transition duration-200\">\r\n\t\t\t\t\t\t\t<svg width=\"13\" height=\"13\" viewBox=\"0 0 13 13\" fill=\"none\" >\r\n\t\t\t\t\t\t\t\t<path d=\"M7.82812 6.5L12.6719 11.3438C12.7109 11.4219 12.75 11.5 12.75 11.5781C12.75 11.6562 12.7109 11.7344 12.6719 11.7734L11.7734 12.6719C11.6953 12.75 11.6172 12.75 11.5391 12.75C11.4609 12.75 11.3828 12.75 11.3438 12.6719L6.5 7.82812L1.65625 12.6719C1.57812 12.75 1.5 12.75 1.42188 12.75C1.34375 12.75 1.26562 12.75 1.22656 12.6719L0.328125 11.7734C0.25 11.7344 0.25 11.6562 0.25 11.5781C0.25 11.5 0.25 11.4219 0.328125 11.3438L5.17188 6.5L0.328125 1.65625C0.25 1.61719 0.25 1.53906 0.25 1.46094C0.25 1.38281 0.25 1.30469 0.328125 1.22656L1.22656 0.328125C1.26562 0.289062 1.34375 0.25 1.42188 0.25C1.5 0.25 1.57812 0.289062 1.65625 0.328125L6.5 5.17188L11.3438 0.328125C11.3828 0.289062 11.4609 0.25 11.5391 0.25C11.6172 0.25 11.6953 0.289062 11.7734 0.328125L12.6719 1.22656C12.7109 1.30469 12.75 1.38281 12.75 1.46094C12.75 1.53906 12.7109 1.61719 12.6719 1.65625L11.8516 2.47656L7.82812 6.5Z\" fill=\"currentColor\"\/>\r\n\t\t\t\t\t\t\t<\/svg>\r\n\t\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"first-name-adult-4\" class=\"block mb-2\">First name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"first-name-adult-4\" id=\"first-name-adult-4\" placeholder=\"Enter your first name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"last-name-adult-4\" class=\"block mb-2\">Last name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"last-name-adult-4\" id=\"last-name-adult-4\" placeholder=\"Enter your last name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"birth-date-adult-4\" class=\"block mb-2\">Date of birth (Required)<\/label>\r\n\t\t\t\t\t<input type=\"date\" name=\"birth-date-adult-4\" id=\"birth-date-adult-4\" placeholder=\"Enter your birthdate\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"gender-adult-4\" class=\"block mb-2\">Gender (Required)<\/label>\r\n\t\t\t\t\t<select type=\"date\" name=\"gender-adult-4\" id=\"gender-adult-4\" placeholder=\"Gender\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t\t\t<option value=\"\">Select<\/option>\t\r\n\t\t\t\t\t\t<option value=\"male\">Male<\/option>\r\n\t\t\t\t\t\t<option value=\"female\">Female<\/option>\r\n\t\t\t\t\t\t<option value=\"other\">Other<\/option>\r\n\t\t\t\t\t<\/select>\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"phone-adult-4\" class=\"block mb-2\">Phone number (Required)<\/label>\r\n\t\t\t\t\t<input type=\"tel\" name=\"phone-adult-4\" id=\"phone-adult-4\" placeholder=\"Enter your phone number\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"email-adult-4\" class=\"block mb-2\">Email (Required)<\/label>\r\n\t\t\t\t\t<input type=\"email\" name=\"email-adult-4\" id=\"email-adult-4\" placeholder=\"Enter your email\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t<\/div>\r\n\t\t<\/section>\r\n\r\n\t\t<section class=\"mt-14 pt-14 border-t border-[#E5E5E5] adult adult-5\">\r\n\t\t\t<div class=\"grid lg:grid-cols-2 gap-[30px]\">\r\n\t\t\t\t<div class=\"lg:col-span-2 flex justify-between items-center\">\r\n\t\t\t\t\t<div class=\"text-xl uppercase font-title\">\r\n\t\t\t\t\t\t<p class=\"!mb-0\">family member (adult)<\/p>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<div class=\"text-right\">\r\n\t\t\t\t\t\t<div class=\"removeAdult cursor-pointer bg-primary text-white w-10 h-10 rounded-full inline-flex items-center justify-center transform hover:scale-105 transition duration-200\">\r\n\t\t\t\t\t\t\t<svg width=\"13\" height=\"13\" viewBox=\"0 0 13 13\" fill=\"none\" >\r\n\t\t\t\t\t\t\t\t<path d=\"M7.82812 6.5L12.6719 11.3438C12.7109 11.4219 12.75 11.5 12.75 11.5781C12.75 11.6562 12.7109 11.7344 12.6719 11.7734L11.7734 12.6719C11.6953 12.75 11.6172 12.75 11.5391 12.75C11.4609 12.75 11.3828 12.75 11.3438 12.6719L6.5 7.82812L1.65625 12.6719C1.57812 12.75 1.5 12.75 1.42188 12.75C1.34375 12.75 1.26562 12.75 1.22656 12.6719L0.328125 11.7734C0.25 11.7344 0.25 11.6562 0.25 11.5781C0.25 11.5 0.25 11.4219 0.328125 11.3438L5.17188 6.5L0.328125 1.65625C0.25 1.61719 0.25 1.53906 0.25 1.46094C0.25 1.38281 0.25 1.30469 0.328125 1.22656L1.22656 0.328125C1.26562 0.289062 1.34375 0.25 1.42188 0.25C1.5 0.25 1.57812 0.289062 1.65625 0.328125L6.5 5.17188L11.3438 0.328125C11.3828 0.289062 11.4609 0.25 11.5391 0.25C11.6172 0.25 11.6953 0.289062 11.7734 0.328125L12.6719 1.22656C12.7109 1.30469 12.75 1.38281 12.75 1.46094C12.75 1.53906 12.7109 1.61719 12.6719 1.65625L11.8516 2.47656L7.82812 6.5Z\" fill=\"currentColor\"\/>\r\n\t\t\t\t\t\t\t<\/svg>\r\n\t\t\t\t\t\t<\/div>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"first-name-adult-5\" class=\"block mb-2\">First name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"first-name-adult-5\" id=\"first-name-adult-5\" placeholder=\"Enter your first name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"last-name-adult-5\" class=\"block mb-2\">Last name (Required)<\/label>\r\n\t\t\t\t\t<input type=\"text\" name=\"last-name-adult-5\" id=\"last-name-adult-5\" placeholder=\"Enter your last name\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"birth-date-adult-5\" class=\"block mb-2\">Date of birth (Required)<\/label>\r\n\t\t\t\t\t<input type=\"date\" name=\"birth-date-adult-5\" id=\"birth-date-adult-5\" placeholder=\"Enter your birthdate\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"gender-adult-5\" class=\"block mb-2\">Gender (Required)<\/label>\r\n\t\t\t\t\t<select type=\"date\" name=\"gender-adult-5\" id=\"gender-adult-5\" placeholder=\"Gender\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t\t\t<option value=\"\">Select<\/option>\t\r\n\t\t\t\t\t\t<option value=\"male\">Male<\/option>\r\n\t\t\t\t\t\t<option value=\"female\">Female<\/option>\r\n\t\t\t\t\t\t<option value=\"other\">Other<\/option>\r\n\t\t\t\t\t<\/select>\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"phone-adult-5\" class=\"block mb-2\">Phone number (Required)<\/label>\r\n\t\t\t\t\t<input type=\"tel\" name=\"phone-adult-5\" id=\"phone-adult-5\" placeholder=\"Enter your phone number\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<div>\r\n\t\t\t\t\t<label for=\"email-adult-5\" class=\"block mb-2\">Email (Required)<\/label>\r\n\t\t\t\t\t<input type=\"email\" name=\"email-adult-5\" id=\"email-adult-5\" placeholder=\"Enter your email\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t\t<\/div>\r\n\r\n\t\t\t<\/div>\r\n\t\t<\/section>\r\n\t<\/div>\r\n\r\n\t<div>\r\n\t\t<div class=\"buttonAddAdult bg-primary-lighter rounded-full text-lg w-full mt-[10px] py-4 px-7 flex uppercase justify-center items-center cursor-pointer font-title hover:bg-primary hover:text-white transition duration-200 select-none disabled:opacity-80 disabled:hover:cursor-not-allowed\">Add a family member (adult)<\/div>\r\n\t<\/div>\r\n\t<div>\r\n\t\t<div class=\"buttonAddChild bg-primary-lighter rounded-full text-lg w-full mt-[10px] py-4 px-7 flex uppercase justify-center items-center cursor-pointer font-title hover:bg-primary hover:text-white transition duration-200 select-none disabled:opacity-80 disabled:hover:cursor-not-allowed\">Add a family member (child)<\/div>\r\n\t<\/div>\r\n\t\r\n\r\n\t<div class=\"lg:col-span-2 text-center\">\r\n\t\t<hr class=\"mt-[10px] mb-[60px] h-px border-[#E5E5E5]\">\r\n\t\t<button type=\"submit\" class=\"bg-primary-medium rounded-full text-xl py-4 px-12 inline-flex uppercase text-white justify-center items-center font-title hover:bg-primary-dark transition duration-200 select-none\">Submit<\/button>\r\n\t<\/div>\r\n\r\n<\/div><noscript>Please enable JavaScript for this form to work.<\/noscript><\/div><\/form><!-- \/ HTML Forms -->","protected":false},"excerpt":{"rendered":"<p>Our practice is always open for new clients.Call us directly for an appointment or fill&#8230;<\/p>\n","protected":false},"author":2,"featured_media":3284,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-106","page","type-page","status-publish","has-post-thumbnail","hentry"],"acf":{"subtitle":"","page_bg":{"background_image":{"ID":3284,"id":3284,"title":"Header_Lassus","filename":"Header_Lassus.jpg","filesize":188694,"url":"https:\/\/lassustandartsen.nl\/oisterwijk\/wp-content\/uploads\/sites\/2\/2023\/01\/Header_Lassus.jpg","link":"https:\/\/lassustandartsen.nl\/amsterdam\/en\/nieuwe-client\/header_lassus-2\/","alt":"","author":"8","description":"","caption":"","name":"header_lassus-2","status":"inherit","uploaded_to":106,"date":"2023-01-20 09:49:24","modified":"2023-01-20 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