www.etobb.com Open in urlscan Pro
5.45.75.44  Public Scan

URL: http://www.etobb.com/
Submission: On October 18 via api from US — Scanned from NL

Form analysis 14 forms found in the DOM

POST

<form method="post" autocomplete="off" class="homepage-search-form mixpanel-ask-above-the-fold">
  <div class="container-fluid">
    <div class="row">
      <div class="col-lg-offset-2 col-md-offset-2 col-sm-offset-2 col-lg-8 col-md-8 col-xs-12 col-sm-8">
        <div class="col-lg-10 col-md-10 col-sm-10 col-xs-9  col-xxs-7 homepage-search-grid-margin">
          <div class="homepage-search">
            <div class="search-question-text-container">
              <div class="search-question-text">
                <input type="text" id="homepage-search-top" placeholder="Type your health question" value="" class="form-control search-search-input homepage_ask_textarea" maxlength="150" onkeydown="SEARCHPAGE.show_hide_x()"
                  onkeyup="SEARCHPAGE.show_hide_x()">
              </div>
              <div class="search-clear pull-right">
                <button type="button" class="close search-clear-btn">×</button>
              </div>
              <div class="clearfix"></div>
            </div>
          </div>
        </div>
        <div class="col-lg-2 col-md-2 col-sm-2 col-xs-3 col-xxs-5 homepage-search-grid-margin">
          <input type="submit" class="btn btn-success pull-left homepage-search-btn" value="Ask">
        </div>
      </div>
    </div>
  </div>
</form>

POST

<form method="post" autocomplete="off" class="homepage-search-form">
  <div class="container-fluid">
    <div class="row">
      <div class="col-lg-offset-2 col-md-offset-2 col-sm-offset-2 col-lg-8 col-md-8 col-xs-12 col-sm-8">
        <div class="col-lg-10 col-md-10 col-sm-10 col-xs-9 col-xxs-7 homepage-search-grid-margin">
          <div class="homepage-search">
            <div class="search-question-text-container">
              <div class="search-question-text">
                <input id="homepage-search-bottom" type="text" placeholder="Type your health question" value="" class="form-control search-search-input homepage_ask_textarea" maxlength="150" onkeydown="SEARCHPAGE.show_hide_x()"
                  onkeyup="SEARCHPAGE.show_hide_x()">
              </div>
              <div class="search-clear pull-right">
                <button type="button" class="close search-clear-btn">×</button>
              </div>
              <div class="clearfix"></div>
            </div>
          </div>
        </div>
        <div class="col-lg-2 col-md-2 col-sm-2 col-xs-3 col-xs-5 homepage-search-grid-margin">
          <input type="submit" class="btn btn-success pull-left homepage-search-btn" value="Ask">
        </div>
      </div>
    </div>
    <br>
  </div>
</form>

POST

<form id="form_login" method="post" data-etb-keep-loading="true" data-etb-form="users/login" data-etb-namespace="login">
  <div class="modal-header">
    <button type="button" class="close" data-dismiss="modal" aria-hidden="true">×</button>
    <span class="heading-gray">Login</span>
  </div>
  <div class="modal-body popup-login-body" tabindex="-1">
    <div class="alert alert-danger alert-error mr15 ml15" role="alert"></div>
    <span class="pl15 pr15">Don't have an account?<a data-target="#popup_register" data-dismiss="modal" data-toggle="modal" class="pointer"> Click here</a> to register.</span>
    <div id="login-with-facebook-container" class="mt15 pl15 pr15 popup-btn-facebook login_with_facebook">
      <div class="pull-left">
        <input type="button" class="btn btn-facebook facebook-icon">
      </div>
      <div class="facebook-button-text">
        <input type="button" class="btn btn-facebook" value="Login with Facebook">
      </div>
      <div class="clearfix"></div>
    </div>
    <div class="separator"></div>
    <div class="m15">Or using your email address:</div>
    <div class="pl15 pr15">
      <input data-etb-input="" data-etb-required="" type="email" id="login_email" name="email" class="form-control popup-login-input" placeholder="Email">
    </div>
    <div class="mt5 pl15 pr15">
      <input data-etb-input="" data-etb-required="" type="password" name="password" id="login_password" class="form-control popup-login-input" placeholder="Password">
    </div>
    <div class="clearfix"></div>
    <div class="mt10 pl15 pr15">
      <a data-target="#popup_password_reset" data-toggle="modal" data-dismiss="modal" class="font13 pointer popup-login-forgot-password">Forgot your password?</a>
    </div>
  </div>
  <div class="modal-footer popup-login-footer">
    <a href="#" class="btn btn-borderless" data-dismiss="modal">Cancel</a>
    <input type="submit" class="btn btn-success" id="login_button" value="Log in">
  </div>
</form>

POST

<form id="form_reset_password" method="post" data-etb-form="users/reset_password">
  <div class="modal-body popup-reset-modal-body" tabindex="-1">
    <div class="alert alert-danger alert-error hide popup-password-reset-alert" role="alert"></div> Please enter the email address you used when registering to receive password reset instructions.<br><br>
    <input class="form-control" data-etb-input="" data-etb-required="" type="email" name="email" id="popup-password-password-reset-email" placeholder="Email">
    <br>
  </div>
  <div class="modal-footer">
    <a href="#" class="btn btn-borderless" data-dismiss="modal">Cancel</a>
    <input type="submit" class="btn btn-success" id="password_reset_button" value="Submit">
  </div>
</form>

POST

<form method="post">
  <div class="modal-body popup-register-modal-body" tabindex="-1">
    <div class="alert alert-danger alert-error popup-register-alert" role="alert"></div>
    <div id="fb_register_success"></div>
    <div class="popup-register-facebook-image-container">
      <img class="popup-register-facebook-image" src="data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAAEAAAABCAAAAAA6fptVAAAACklEQVR4nGP6DwABBQECz6AuzQAAAABJRU5ErkJggg==" width="100" height="100" alt="profile picture">
    </div>
    <div class="popup-register-patient-only">
      <div class="popup-register-facebook-btn-container register_with_facebook">
        <div class="pull-left">
          <input type="button" class="btn btn-facebook facebook-icon">
        </div>
        <div class="facebook-button-text">
          <input type="button" class="btn btn-facebook" value="Register with Facebook">
        </div>
        <div class="clearfix"></div>
      </div>
      <div class="popup-register-signup-text"> We will never share your information or post anything on your behalf. </div>
      <div class="popup-register-signup-email-address"> Or using your email address: </div>
    </div>
    <div class="mt10">
      <div class="popup-register-signup-input-container popup-register-signup-input-container-first-name pull-left">
        <input class="form-control popup-register-signup-input" placeholder="First Name" id="popup-register-first-name">
        <div class="popup-register-signup-name-icon sprite sprite-name"></div>
      </div>
      <div class="popup-register-signup-input-container popup-register-signup-input-container-last-name">
        <input class="form-control popup-register-signup-input popup-register-signup-input-noicon" placeholder="Last Name" id="popup-register-last-name">
      </div>
    </div>
    <div class="popup-register-signup-input-container popup-register-signup-email">
      <input type="email" name="email" class="form-control popup-register-signup-input" placeholder="Email" id="popup-register-email">
      <div class="popup-register-signup-email-icon sprite sprite-email"></div>
    </div>
    <div class="popup-register-signup-input-container popup-register-signup-password">
      <input type="password" name="password" class="form-control popup-register-signup-input" placeholder="Password" id="popup-register-password">
      <div class="popup-register-signup-password-icon sprite sprite-password"></div>
    </div>
    <div id="popup-register-doctor-link" class="checkbox">
      <a href="/doctor-homepage">I am a doctor</a>
    </div>
    <div class="popup-register-signup-disclaimer"> By signing up, you indicate that you have read and agreed to the <a href="/terms" target="_blank">
							Terms 						</a> and <a href="/privacy" target="_blank">
							Policy						</a>
    </div>
  </div>
  <div class="modal-footer">
    <a href="#" class="btn btn-borderless" data-dismiss="modal">Cancel</a>
    <input type="submit" class="btn btn-success" value="Register" id="popup_register_button">
    <input type="reset" class="hidden" id="reset_register">
  </div>
</form>

POST

<form method="post" id="report_form">
  <div class="modal-header">
    <button type="button" class="close" data-dismiss="modal" aria-hidden="true">×</button>
    <h4 class="heading_gray">Report <span class="report_type"></span></h4>
  </div>
  <div class="modal-body" tabindex="-1">
    <input type="hidden" id="report_post_id" value="">
    <div class="alert alert-error hide fade in"></div>
    <p>Please select one of the reasons below: </p>
    <label class="radio popup-report-radio">
      <input type="radio" name="reason" value="spam">Spam<br>
    </label>
    <label class="radio popup-report-radio">
      <input type="radio" name="reason" value="inaccurate_information">Inaccurate information<br>
    </label>
    <label class="radio popup-report-radio">
      <input type="radio" name="reason" value="misleading">Misleading<br>
    </label>
    <label class="radio popup-report-radio">
      <input type="radio" name="reason" value="sexually_explicit">Sexually explicit<br>
    </label>
    <label class="radio popup-report-radio">
      <input type="radio" name="reason" value="repetitive">Repetitive<br>
    </label>
    <label class="radio popup-report-radio">
      <input type="radio" name="reason" id="report_other_radio" value="other">Other<br>
    </label>
    <textarea id="popup-report-text-area" class="form-control" placeholder="Additional information"></textarea>
  </div>
  <div class="modal-footer">
    <a href="#" class="btn btn-borderless" data-dismiss="modal">Cancel</a>
    <input type="submit" class="btn btn-danger" value="Report" id="report_button">
  </div>
</form>

POST

<form method="post">
  <div class="modal-body" tabindex="-1">
    <div class="alert alert-danger alert-error" role="alert"></div>
    <div>
      <div class="popup-basic-booking-inputs pull-left">
        <input id="popup-basic-booking-firstname" class="form-control popup-basic-booking-first-name-input" placeholder="First name">
      </div>
      <div class="popup-basic-booking-first-name-icon sprite sprite-name"></div>
      <div class="popup-basic-booking-middle-input pull-left">
        <input id="popup-basic-booking-fathersname" class="form-control popup-basic-booking-fathers-name-input" placeholder="Father's name">
      </div>
      <div class="popup-basic-booking-inputs pull-left">
        <input id="popup-basic-booking-lastname" class="form-control popup-basic-booking-last-name-input" placeholder="Last name">
      </div>
    </div>
    <div class="clearfix"></div>
    <div class="popup-basic-booking-email-input-container">
      <input id="popup-basic-booking-email" class="form-control popup-basic-booking-email-input" placeholder="Email">
    </div>
    <div class="popup-basic-booking-email-icon sprite sprite-email"></div>
    <div class="popup-basic-booking-number-input-container">
      <div class="pull-left popup-basic-booking-country-container select2">
        <div class="select2-container form-control popup-basic-booking-country popup-basic-booking-mobile-country" id="s2id_popup-basic-booking-mobile-country">
          <a href="javascript:void(0)" class="select2-choice" tabindex="-1">   <span class="select2-chosen" id="select2-chosen-1">Lebanon +961</span><abbr class="select2-search-choice-close"></abbr>   <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
            for="s2id_autogen1" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-1" id="s2id_autogen1">
          <div class="select2-drop select2-display-none select2-with-searchbox">
            <div class="select2-search"> <label for="s2id_autogen1_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" class="select2-input" role="combobox"
                aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-1" id="s2id_autogen1_search" placeholder=""> </div>
            <ul class="select2-results" role="listbox" id="select2-results-1"> </ul>
          </div>
        </div><select id="popup-basic-booking-mobile-country" class="form-control popup-basic-booking-country popup-basic-booking-mobile-country select2-init" tabindex="-1" title="" style="display: none;">
          <option value="961" data-country-code="LB">Lebanon +961</option>
          <option value="93" data-country-code="AD">Andorra +93</option>
          <option value="376" data-country-code="AE">United Arab Emirates +376</option>
          <option value="971" data-country-code="AF">Afghanistan +971</option>
          <option value="1" data-country-code="AG">Antigua and Barbuda +1</option>
          <option value="1" data-country-code="AI">Anguilla +1</option>
          <option value="355" data-country-code="AL">Albania +355</option>
          <option value="374" data-country-code="AM">Armenia +374</option>
          <option value="599" data-country-code="AN">Netherlands Antilles +599</option>
          <option value="244" data-country-code="AO">Angola +244</option>
          <option value="54" data-country-code="AR">Argentina +54</option>
          <option value="1" data-country-code="AS">American Samoa +1</option>
          <option value="43" data-country-code="AT">Austria +43</option>
          <option value="61" data-country-code="AU">Australia +61</option>
          <option value="297" data-country-code="AW">Aruba +297</option>
          <option value="994" data-country-code="AZ">Azerbaijan +994</option>
          <option value="387" data-country-code="BA">Bosnia and Herzegovina +387</option>
          <option value="1" data-country-code="BB">Barbados +1</option>
          <option value="880" data-country-code="BD">Bangladesh +880</option>
          <option value="32" data-country-code="BE">Belgium +32</option>
          <option value="226" data-country-code="BF">Burkina Faso +226</option>
          <option value="359" data-country-code="BG">Bulgaria +359</option>
          <option value="973" data-country-code="BH">Bahrain +973</option>
          <option value="257" data-country-code="BI">Burundi +257</option>
          <option value="229" data-country-code="BJ">Benin +229</option>
          <option value="1" data-country-code="BM">Bermuda +1</option>
          <option value="673" data-country-code="BN">Brunei Darussala +673</option>
          <option value="591" data-country-code="BO">Bolivia +591</option>
          <option value="55" data-country-code="BR">Brazil +55</option>
          <option value="1" data-country-code="BS">Bahamas +1</option>
          <option value="975" data-country-code="BT">Bhutan +975</option>
          <option value="267" data-country-code="BW">Botswana +267</option>
          <option value="375" data-country-code="BY">Belarus +375</option>
          <option value="501" data-country-code="BZ">Belize +501</option>
          <option value="1" data-country-code="CA">Canada +1</option>
          <option value="243" data-country-code="CD">Democratic Republic of Congo +243</option>
          <option value="236" data-country-code="CF">Central African Republic +236</option>
          <option value="242" data-country-code="CG">Congo +242</option>
          <option value="41" data-country-code="CH">Switzerland +41</option>
          <option value="225" data-country-code="CI">Côte d’Ivoire +225</option>
          <option value="682" data-country-code="CK">Cook Islands +682</option>
          <option value="56" data-country-code="CL">Chile +56</option>
          <option value="237" data-country-code="CM">Cameroon +237</option>
          <option value="86" data-country-code="CN">China +86</option>
          <option value="57" data-country-code="CO">Colombia +57</option>
          <option value="506" data-country-code="CR">Costa Rica +506</option>
          <option value="53" data-country-code="CU">Cuba +53</option>
          <option value="238" data-country-code="CV">Cape Verde +238</option>
          <option value="357" data-country-code="CY">Cyprus +357</option>
          <option value="420" data-country-code="CZ">Czech Republic +420</option>
          <option value="49" data-country-code="DE">Germany +49</option>
          <option value="253" data-country-code="DJ">Djibouti +253</option>
          <option value="45" data-country-code="DK">Denmark +45</option>
          <option value="1" data-country-code="DM">Dominica +1</option>
          <option value="1809" data-country-code="DO">Dominican Republic +1809</option>
          <option value="213" data-country-code="DZ">Algeria +213</option>
          <option value="593" data-country-code="EC">Ecuador +593</option>
          <option value="372" data-country-code="EE">Estonia +372</option>
          <option value="20" data-country-code="EG">Egypt +20</option>
          <option value="291" data-country-code="ER">Eritrea +291</option>
          <option value="34" data-country-code="ES">Spain +34</option>
          <option value="251" data-country-code="ET">Ethiopia +251</option>
          <option value="358" data-country-code="FI">Finland +358</option>
          <option value="679" data-country-code="FJ">Fiji +679</option>
          <option value="500" data-country-code="FK">Falkland Islands (malvinas) +500</option>
          <option value="691" data-country-code="FM">Micronesia, Federated States of +691</option>
          <option value="298" data-country-code="FO">Faroe Islands +298</option>
          <option value="33" data-country-code="FR">France +33</option>
          <option value="241" data-country-code="GA">Gabon +241</option>
          <option value="44" data-country-code="GB">United Kingdom +44</option>
          <option value="1" data-country-code="GD">Grenada +1</option>
          <option value="995" data-country-code="GE">Georgia +995</option>
          <option value="594" data-country-code="GF">French Guiana +594</option>
          <option value="233" data-country-code="GH">Ghana +233</option>
          <option value="350" data-country-code="GI">Gibraltar +350</option>
          <option value="299" data-country-code="GL">Greenland +299</option>
          <option value="220" data-country-code="GM">Gambia +220</option>
          <option value="224" data-country-code="GN">Guinea +224</option>
          <option value="590" data-country-code="GP">Guadeloupe +590</option>
          <option value="240" data-country-code="GQ">Equatorial Guinea +240</option>
          <option value="30" data-country-code="GR">Greece +30</option>
          <option value="502" data-country-code="GT">Guatemala +502</option>
          <option value="1" data-country-code="GU">Guam +1</option>
          <option value="245" data-country-code="GW">Guinea-Bissau +245</option>
          <option value="592" data-country-code="GY">Guyana +592</option>
          <option value="852" data-country-code="HK">Hong Kong +852</option>
          <option value="504" data-country-code="HN">Honduras +504</option>
          <option value="385" data-country-code="HR">Croatia +385</option>
          <option value="509" data-country-code="HT">Haiti +509</option>
          <option value="36" data-country-code="HU">Hungary +36</option>
          <option value="62" data-country-code="ID">Indonesia +62</option>
          <option value="353" data-country-code="IE">Ireland +353</option>
          <option value="91" data-country-code="IN">India +91</option>
          <option value="964" data-country-code="IQ">Iraq +964</option>
          <option value="98" data-country-code="IR">Iran (Islamic Republic of) +98</option>
          <option value="354" data-country-code="IS">Iceland +354</option>
          <option value="39" data-country-code="IT">Italy +39</option>
          <option value="1" data-country-code="JM">Jamaica +1</option>
          <option value="962" data-country-code="JO">Jordan +962</option>
          <option value="81" data-country-code="JP">Japan +81</option>
          <option value="254" data-country-code="KE">Kenya +254</option>
          <option value="996" data-country-code="KG">Kyrgyzstan +996</option>
          <option value="855" data-country-code="KH">Cambodia +855</option>
          <option value="686" data-country-code="KI">Kiribati +686</option>
          <option value="269" data-country-code="KM">Comoros +269</option>
          <option value="1" data-country-code="KN">Saint Kitts and Nevis +1</option>
          <option value="850" data-country-code="KP">Korea, D.p.r.o. +850</option>
          <option value="82" data-country-code="KR">Korea, Republic of +82</option>
          <option value="965" data-country-code="KW">Kuwait +965</option>
          <option value="1" data-country-code="KY">Cayman Islands +1</option>
          <option value="7" data-country-code="KZ">Kazakhstan +7</option>
          <option value="856" data-country-code="LA">Laos +856</option>
          <option value="1" data-country-code="LC">Saint Lucia +1</option>
          <option value="423" data-country-code="LI">Liechtenstein +423</option>
          <option value="94" data-country-code="LK">Sri Lanka +94</option>
          <option value="231" data-country-code="LR">Liberia +231</option>
          <option value="266" data-country-code="LS">Lesotho +266</option>
          <option value="370" data-country-code="LT">Lithuania +370</option>
          <option value="352" data-country-code="LU">Luxembourg +352</option>
          <option value="371" data-country-code="LV">Latvia +371</option>
          <option value="218" data-country-code="LY">Libyan Arab Jamahiriya +218</option>
          <option value="212" data-country-code="MA">Morocco +212</option>
          <option value="377" data-country-code="MC">Monaco +377</option>
          <option value="373" data-country-code="MD">Moldova, Republic of +373</option>
          <option value="382" data-country-code="ME">Montenegro +382</option>
          <option value="261" data-country-code="MG">Madagascar +261</option>
          <option value="692" data-country-code="MH">Marshall Islands +692</option>
          <option value="389" data-country-code="MK">Macedonia +389</option>
          <option value="223" data-country-code="ML">Mali +223</option>
          <option value="95" data-country-code="MM">Myanmar (Burma) +95</option>
          <option value="976" data-country-code="MN">Mongolia +976</option>
          <option value="853" data-country-code="MO">Macau +853</option>
          <option value="1" data-country-code="MP">Northern Mariana Islands +1</option>
          <option value="596" data-country-code="MQ">Martinique +596</option>
          <option value="222" data-country-code="MR">Mauritania +222</option>
          <option value="1" data-country-code="MS">Montserrat +1</option>
          <option value="356" data-country-code="MT">Malta +356</option>
          <option value="230" data-country-code="MU">Mauritius +230</option>
          <option value="960" data-country-code="MV">Maldives +960</option>
          <option value="265" data-country-code="MW">Malawi +265</option>
          <option value="52" data-country-code="MX">Mexico +52</option>
          <option value="60" data-country-code="MY">Malaysia +60</option>
          <option value="258" data-country-code="MZ">Mozambique +258</option>
          <option value="264" data-country-code="NA">Namibia +264</option>
          <option value="687" data-country-code="NC">New Caledonia +687</option>
          <option value="227" data-country-code="NE">Niger +227</option>
          <option value="6723" data-country-code="NF">Norfolk Island +6723</option>
          <option value="234" data-country-code="NG">Nigeria +234</option>
          <option value="505" data-country-code="NI">Nicaragua +505</option>
          <option value="31" data-country-code="NL">Netherlands +31</option>
          <option value="47" data-country-code="NO">Norway +47</option>
          <option value="977" data-country-code="NP">Nepal +977</option>
          <option value="674" data-country-code="NR">Nauru +674</option>
          <option value="683" data-country-code="NU">Niue +683</option>
          <option value="64" data-country-code="NZ">New Zealand +64</option>
          <option value="968" data-country-code="OM">Oman +968</option>
          <option value="507" data-country-code="PA">Panama +507</option>
          <option value="51" data-country-code="PE">Peru +51</option>
          <option value="689" data-country-code="PF">French Polynesia +689</option>
          <option value="675" data-country-code="PG">Papua New Guinea +675</option>
          <option value="63" data-country-code="PH">Philippines +63</option>
          <option value="92" data-country-code="PK">Pakistan +92</option>
          <option value="48" data-country-code="PL">Poland +48</option>
          <option value="508" data-country-code="PM">St. Pierre and Miquelon +508</option>
          <option value="1" data-country-code="PR">Puerto Rico +1</option>
          <option value="970" data-country-code="PS">Palestine +970</option>
          <option value="351" data-country-code="PT">Portugal +351</option>
          <option value="680" data-country-code="PW">Palau +680</option>
          <option value="595" data-country-code="PY">Paraguay +595</option>
          <option value="974" data-country-code="QA">Qatar +974</option>
          <option value="262" data-country-code="RE">Réunion +262</option>
          <option value="40" data-country-code="RO">Romania +40</option>
          <option value="381" data-country-code="RS">Serbia +381</option>
          <option value="7" data-country-code="RU">Russian Federation +7</option>
          <option value="250" data-country-code="RW">Rwanda +250</option>
          <option value="966" data-country-code="SA">Saudi Arabia +966</option>
          <option value="677" data-country-code="SB">Solomon Islands +677</option>
          <option value="248" data-country-code="SC">Seychelles +248</option>
          <option value="249" data-country-code="SD">Sudan +249</option>
          <option value="46" data-country-code="SE">Sweden +46</option>
          <option value="65" data-country-code="SG">Singapore +65</option>
          <option value="290" data-country-code="SH">St. Helena +290</option>
          <option value="386" data-country-code="SI">Slovenia +386</option>
          <option value="421" data-country-code="SK">Slovakia (slovak Republic) +421</option>
          <option value="232" data-country-code="SL">Sierra Leone +232</option>
          <option value="378" data-country-code="SM">San Marino +378</option>
          <option value="221" data-country-code="SN">Senegal +221</option>
          <option value="252" data-country-code="SO">Somalia +252</option>
          <option value="597" data-country-code="SR">Suriname +597</option>
          <option value="211" data-country-code="SS">South Sudan +211</option>
          <option value="239" data-country-code="ST">São Tomé and Príncipe +239</option>
          <option value="503" data-country-code="SV">El Salvador +503</option>
          <option value="963" data-country-code="SY">Syria +963</option>
          <option value="268" data-country-code="SZ">Swaziland +268</option>
          <option value="1" data-country-code="TC">Turks and Caicos Islands +1</option>
          <option value="235" data-country-code="TD">Chad +235</option>
          <option value="228" data-country-code="TG">Togo +228</option>
          <option value="66" data-country-code="TH">Thailand +66</option>
          <option value="992" data-country-code="TJ">Tajikistan +992</option>
          <option value="690" data-country-code="TK">Tokelau +690</option>
          <option value="993" data-country-code="TM">Turkmenistan +993</option>
          <option value="216" data-country-code="TN">Tunisia +216</option>
          <option value="676" data-country-code="TO">Tonga +676</option>
          <option value="670" data-country-code="TP">East Timor +670</option>
          <option value="90" data-country-code="TR">Turkey +90</option>
          <option value="1" data-country-code="TT">Trinidad and Tobago +1</option>
          <option value="688" data-country-code="TV">Tuvalu +688</option>
          <option value="886" data-country-code="TW">Taiwan, Province of China +886</option>
          <option value="255" data-country-code="TZ">Tanzania +255</option>
          <option value="380" data-country-code="UA">Ukraine +380</option>
          <option value="256" data-country-code="UG">Uganda +256</option>
          <option value="1" data-country-code="US">United States +1</option>
          <option value="598" data-country-code="UY">Uruguay +598</option>
          <option value="998" data-country-code="UZ">Uzbekistan +998</option>
          <option value="379" data-country-code="VA">Holy See (vatican City State) +379</option>
          <option value="1" data-country-code="VC">Saint Vincent and the Grenadines +1</option>
          <option value="58" data-country-code="VE">Venezuela +58</option>
          <option value="84" data-country-code="VG">Virgin Islands (British) +84</option>
          <option value="1" data-country-code="VI">Virgin Islands (U.S.) +1</option>
          <option value="84" data-country-code="VN">Vietnam +84</option>
          <option value="678" data-country-code="VU">Vanuatu +678</option>
          <option value="681" data-country-code="WF">Wallis and Futuna Islands +681</option>
          <option value="685" data-country-code="WS">Samoa +685</option>
          <option value="967" data-country-code="YE">Yemen +967</option>
          <option value="262" data-country-code="YT">Mayotte +262</option>
          <option value="27" data-country-code="ZA">South Africa +27</option>
          <option value="260" data-country-code="ZM">Zambia +260</option>
          <option value="263" data-country-code="ZW">Zimbabwe +263</option>
        </select>
      </div>
      <div class="popup-basic-booking-phone-input-container">
        <input id="popup-basic-booking-mobile" class="form-control popup-basic-booking-phone-input" placeholder="Mobile number">
        <div class="popup-basic-booking-mobile-icon sprite sprite-mobile"></div>
      </div>
    </div>
    <div class="popup-basic-booking-country-icon sprite sprite-location"></div>
    <div class="popup-basic-booking-number-input-container">
      <div class="pull-left popup-basic-booking-country-container select2">
        <div class="select2-container form-control popup-basic-booking-country popup-basic-booking-mobile-country" id="s2id_popup-basic-booking-home-country">
          <a href="javascript:void(0)" class="select2-choice" tabindex="-1">   <span class="select2-chosen" id="select2-chosen-2">Lebanon +961</span><abbr class="select2-search-choice-close"></abbr>   <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
            for="s2id_autogen2" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-2" id="s2id_autogen2">
          <div class="select2-drop select2-display-none select2-with-searchbox">
            <div class="select2-search"> <label for="s2id_autogen2_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" class="select2-input" role="combobox"
                aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-2" id="s2id_autogen2_search" placeholder=""> </div>
            <ul class="select2-results" role="listbox" id="select2-results-2"> </ul>
          </div>
        </div><select id="popup-basic-booking-home-country" class="form-control popup-basic-booking-country popup-basic-booking-mobile-country select2-init" tabindex="-1" title="" style="display: none;">
          <option value="961" data-country-code="LB">Lebanon +961</option>
          <option value="93" data-country-code="AD">Andorra +93</option>
          <option value="376" data-country-code="AE">United Arab Emirates +376</option>
          <option value="971" data-country-code="AF">Afghanistan +971</option>
          <option value="1" data-country-code="AG">Antigua and Barbuda +1</option>
          <option value="1" data-country-code="AI">Anguilla +1</option>
          <option value="355" data-country-code="AL">Albania +355</option>
          <option value="374" data-country-code="AM">Armenia +374</option>
          <option value="599" data-country-code="AN">Netherlands Antilles +599</option>
          <option value="244" data-country-code="AO">Angola +244</option>
          <option value="54" data-country-code="AR">Argentina +54</option>
          <option value="1" data-country-code="AS">American Samoa +1</option>
          <option value="43" data-country-code="AT">Austria +43</option>
          <option value="61" data-country-code="AU">Australia +61</option>
          <option value="297" data-country-code="AW">Aruba +297</option>
          <option value="994" data-country-code="AZ">Azerbaijan +994</option>
          <option value="387" data-country-code="BA">Bosnia and Herzegovina +387</option>
          <option value="1" data-country-code="BB">Barbados +1</option>
          <option value="880" data-country-code="BD">Bangladesh +880</option>
          <option value="32" data-country-code="BE">Belgium +32</option>
          <option value="226" data-country-code="BF">Burkina Faso +226</option>
          <option value="359" data-country-code="BG">Bulgaria +359</option>
          <option value="973" data-country-code="BH">Bahrain +973</option>
          <option value="257" data-country-code="BI">Burundi +257</option>
          <option value="229" data-country-code="BJ">Benin +229</option>
          <option value="1" data-country-code="BM">Bermuda +1</option>
          <option value="673" data-country-code="BN">Brunei Darussala +673</option>
          <option value="591" data-country-code="BO">Bolivia +591</option>
          <option value="55" data-country-code="BR">Brazil +55</option>
          <option value="1" data-country-code="BS">Bahamas +1</option>
          <option value="975" data-country-code="BT">Bhutan +975</option>
          <option value="267" data-country-code="BW">Botswana +267</option>
          <option value="375" data-country-code="BY">Belarus +375</option>
          <option value="501" data-country-code="BZ">Belize +501</option>
          <option value="1" data-country-code="CA">Canada +1</option>
          <option value="243" data-country-code="CD">Democratic Republic of Congo +243</option>
          <option value="236" data-country-code="CF">Central African Republic +236</option>
          <option value="242" data-country-code="CG">Congo +242</option>
          <option value="41" data-country-code="CH">Switzerland +41</option>
          <option value="225" data-country-code="CI">Côte d’Ivoire +225</option>
          <option value="682" data-country-code="CK">Cook Islands +682</option>
          <option value="56" data-country-code="CL">Chile +56</option>
          <option value="237" data-country-code="CM">Cameroon +237</option>
          <option value="86" data-country-code="CN">China +86</option>
          <option value="57" data-country-code="CO">Colombia +57</option>
          <option value="506" data-country-code="CR">Costa Rica +506</option>
          <option value="53" data-country-code="CU">Cuba +53</option>
          <option value="238" data-country-code="CV">Cape Verde +238</option>
          <option value="357" data-country-code="CY">Cyprus +357</option>
          <option value="420" data-country-code="CZ">Czech Republic +420</option>
          <option value="49" data-country-code="DE">Germany +49</option>
          <option value="253" data-country-code="DJ">Djibouti +253</option>
          <option value="45" data-country-code="DK">Denmark +45</option>
          <option value="1" data-country-code="DM">Dominica +1</option>
          <option value="1809" data-country-code="DO">Dominican Republic +1809</option>
          <option value="213" data-country-code="DZ">Algeria +213</option>
          <option value="593" data-country-code="EC">Ecuador +593</option>
          <option value="372" data-country-code="EE">Estonia +372</option>
          <option value="20" data-country-code="EG">Egypt +20</option>
          <option value="291" data-country-code="ER">Eritrea +291</option>
          <option value="34" data-country-code="ES">Spain +34</option>
          <option value="251" data-country-code="ET">Ethiopia +251</option>
          <option value="358" data-country-code="FI">Finland +358</option>
          <option value="679" data-country-code="FJ">Fiji +679</option>
          <option value="500" data-country-code="FK">Falkland Islands (malvinas) +500</option>
          <option value="691" data-country-code="FM">Micronesia, Federated States of +691</option>
          <option value="298" data-country-code="FO">Faroe Islands +298</option>
          <option value="33" data-country-code="FR">France +33</option>
          <option value="241" data-country-code="GA">Gabon +241</option>
          <option value="44" data-country-code="GB">United Kingdom +44</option>
          <option value="1" data-country-code="GD">Grenada +1</option>
          <option value="995" data-country-code="GE">Georgia +995</option>
          <option value="594" data-country-code="GF">French Guiana +594</option>
          <option value="233" data-country-code="GH">Ghana +233</option>
          <option value="350" data-country-code="GI">Gibraltar +350</option>
          <option value="299" data-country-code="GL">Greenland +299</option>
          <option value="220" data-country-code="GM">Gambia +220</option>
          <option value="224" data-country-code="GN">Guinea +224</option>
          <option value="590" data-country-code="GP">Guadeloupe +590</option>
          <option value="240" data-country-code="GQ">Equatorial Guinea +240</option>
          <option value="30" data-country-code="GR">Greece +30</option>
          <option value="502" data-country-code="GT">Guatemala +502</option>
          <option value="1" data-country-code="GU">Guam +1</option>
          <option value="245" data-country-code="GW">Guinea-Bissau +245</option>
          <option value="592" data-country-code="GY">Guyana +592</option>
          <option value="852" data-country-code="HK">Hong Kong +852</option>
          <option value="504" data-country-code="HN">Honduras +504</option>
          <option value="385" data-country-code="HR">Croatia +385</option>
          <option value="509" data-country-code="HT">Haiti +509</option>
          <option value="36" data-country-code="HU">Hungary +36</option>
          <option value="62" data-country-code="ID">Indonesia +62</option>
          <option value="353" data-country-code="IE">Ireland +353</option>
          <option value="91" data-country-code="IN">India +91</option>
          <option value="964" data-country-code="IQ">Iraq +964</option>
          <option value="98" data-country-code="IR">Iran (Islamic Republic of) +98</option>
          <option value="354" data-country-code="IS">Iceland +354</option>
          <option value="39" data-country-code="IT">Italy +39</option>
          <option value="1" data-country-code="JM">Jamaica +1</option>
          <option value="962" data-country-code="JO">Jordan +962</option>
          <option value="81" data-country-code="JP">Japan +81</option>
          <option value="254" data-country-code="KE">Kenya +254</option>
          <option value="996" data-country-code="KG">Kyrgyzstan +996</option>
          <option value="855" data-country-code="KH">Cambodia +855</option>
          <option value="686" data-country-code="KI">Kiribati +686</option>
          <option value="269" data-country-code="KM">Comoros +269</option>
          <option value="1" data-country-code="KN">Saint Kitts and Nevis +1</option>
          <option value="850" data-country-code="KP">Korea, D.p.r.o. +850</option>
          <option value="82" data-country-code="KR">Korea, Republic of +82</option>
          <option value="965" data-country-code="KW">Kuwait +965</option>
          <option value="1" data-country-code="KY">Cayman Islands +1</option>
          <option value="7" data-country-code="KZ">Kazakhstan +7</option>
          <option value="856" data-country-code="LA">Laos +856</option>
          <option value="1" data-country-code="LC">Saint Lucia +1</option>
          <option value="423" data-country-code="LI">Liechtenstein +423</option>
          <option value="94" data-country-code="LK">Sri Lanka +94</option>
          <option value="231" data-country-code="LR">Liberia +231</option>
          <option value="266" data-country-code="LS">Lesotho +266</option>
          <option value="370" data-country-code="LT">Lithuania +370</option>
          <option value="352" data-country-code="LU">Luxembourg +352</option>
          <option value="371" data-country-code="LV">Latvia +371</option>
          <option value="218" data-country-code="LY">Libyan Arab Jamahiriya +218</option>
          <option value="212" data-country-code="MA">Morocco +212</option>
          <option value="377" data-country-code="MC">Monaco +377</option>
          <option value="373" data-country-code="MD">Moldova, Republic of +373</option>
          <option value="382" data-country-code="ME">Montenegro +382</option>
          <option value="261" data-country-code="MG">Madagascar +261</option>
          <option value="692" data-country-code="MH">Marshall Islands +692</option>
          <option value="389" data-country-code="MK">Macedonia +389</option>
          <option value="223" data-country-code="ML">Mali +223</option>
          <option value="95" data-country-code="MM">Myanmar (Burma) +95</option>
          <option value="976" data-country-code="MN">Mongolia +976</option>
          <option value="853" data-country-code="MO">Macau +853</option>
          <option value="1" data-country-code="MP">Northern Mariana Islands +1</option>
          <option value="596" data-country-code="MQ">Martinique +596</option>
          <option value="222" data-country-code="MR">Mauritania +222</option>
          <option value="1" data-country-code="MS">Montserrat +1</option>
          <option value="356" data-country-code="MT">Malta +356</option>
          <option value="230" data-country-code="MU">Mauritius +230</option>
          <option value="960" data-country-code="MV">Maldives +960</option>
          <option value="265" data-country-code="MW">Malawi +265</option>
          <option value="52" data-country-code="MX">Mexico +52</option>
          <option value="60" data-country-code="MY">Malaysia +60</option>
          <option value="258" data-country-code="MZ">Mozambique +258</option>
          <option value="264" data-country-code="NA">Namibia +264</option>
          <option value="687" data-country-code="NC">New Caledonia +687</option>
          <option value="227" data-country-code="NE">Niger +227</option>
          <option value="6723" data-country-code="NF">Norfolk Island +6723</option>
          <option value="234" data-country-code="NG">Nigeria +234</option>
          <option value="505" data-country-code="NI">Nicaragua +505</option>
          <option value="31" data-country-code="NL">Netherlands +31</option>
          <option value="47" data-country-code="NO">Norway +47</option>
          <option value="977" data-country-code="NP">Nepal +977</option>
          <option value="674" data-country-code="NR">Nauru +674</option>
          <option value="683" data-country-code="NU">Niue +683</option>
          <option value="64" data-country-code="NZ">New Zealand +64</option>
          <option value="968" data-country-code="OM">Oman +968</option>
          <option value="507" data-country-code="PA">Panama +507</option>
          <option value="51" data-country-code="PE">Peru +51</option>
          <option value="689" data-country-code="PF">French Polynesia +689</option>
          <option value="675" data-country-code="PG">Papua New Guinea +675</option>
          <option value="63" data-country-code="PH">Philippines +63</option>
          <option value="92" data-country-code="PK">Pakistan +92</option>
          <option value="48" data-country-code="PL">Poland +48</option>
          <option value="508" data-country-code="PM">St. Pierre and Miquelon +508</option>
          <option value="1" data-country-code="PR">Puerto Rico +1</option>
          <option value="970" data-country-code="PS">Palestine +970</option>
          <option value="351" data-country-code="PT">Portugal +351</option>
          <option value="680" data-country-code="PW">Palau +680</option>
          <option value="595" data-country-code="PY">Paraguay +595</option>
          <option value="974" data-country-code="QA">Qatar +974</option>
          <option value="262" data-country-code="RE">Réunion +262</option>
          <option value="40" data-country-code="RO">Romania +40</option>
          <option value="381" data-country-code="RS">Serbia +381</option>
          <option value="7" data-country-code="RU">Russian Federation +7</option>
          <option value="250" data-country-code="RW">Rwanda +250</option>
          <option value="966" data-country-code="SA">Saudi Arabia +966</option>
          <option value="677" data-country-code="SB">Solomon Islands +677</option>
          <option value="248" data-country-code="SC">Seychelles +248</option>
          <option value="249" data-country-code="SD">Sudan +249</option>
          <option value="46" data-country-code="SE">Sweden +46</option>
          <option value="65" data-country-code="SG">Singapore +65</option>
          <option value="290" data-country-code="SH">St. Helena +290</option>
          <option value="386" data-country-code="SI">Slovenia +386</option>
          <option value="421" data-country-code="SK">Slovakia (slovak Republic) +421</option>
          <option value="232" data-country-code="SL">Sierra Leone +232</option>
          <option value="378" data-country-code="SM">San Marino +378</option>
          <option value="221" data-country-code="SN">Senegal +221</option>
          <option value="252" data-country-code="SO">Somalia +252</option>
          <option value="597" data-country-code="SR">Suriname +597</option>
          <option value="211" data-country-code="SS">South Sudan +211</option>
          <option value="239" data-country-code="ST">São Tomé and Príncipe +239</option>
          <option value="503" data-country-code="SV">El Salvador +503</option>
          <option value="963" data-country-code="SY">Syria +963</option>
          <option value="268" data-country-code="SZ">Swaziland +268</option>
          <option value="1" data-country-code="TC">Turks and Caicos Islands +1</option>
          <option value="235" data-country-code="TD">Chad +235</option>
          <option value="228" data-country-code="TG">Togo +228</option>
          <option value="66" data-country-code="TH">Thailand +66</option>
          <option value="992" data-country-code="TJ">Tajikistan +992</option>
          <option value="690" data-country-code="TK">Tokelau +690</option>
          <option value="993" data-country-code="TM">Turkmenistan +993</option>
          <option value="216" data-country-code="TN">Tunisia +216</option>
          <option value="676" data-country-code="TO">Tonga +676</option>
          <option value="670" data-country-code="TP">East Timor +670</option>
          <option value="90" data-country-code="TR">Turkey +90</option>
          <option value="1" data-country-code="TT">Trinidad and Tobago +1</option>
          <option value="688" data-country-code="TV">Tuvalu +688</option>
          <option value="886" data-country-code="TW">Taiwan, Province of China +886</option>
          <option value="255" data-country-code="TZ">Tanzania +255</option>
          <option value="380" data-country-code="UA">Ukraine +380</option>
          <option value="256" data-country-code="UG">Uganda +256</option>
          <option value="1" data-country-code="US">United States +1</option>
          <option value="598" data-country-code="UY">Uruguay +598</option>
          <option value="998" data-country-code="UZ">Uzbekistan +998</option>
          <option value="379" data-country-code="VA">Holy See (vatican City State) +379</option>
          <option value="1" data-country-code="VC">Saint Vincent and the Grenadines +1</option>
          <option value="58" data-country-code="VE">Venezuela +58</option>
          <option value="84" data-country-code="VG">Virgin Islands (British) +84</option>
          <option value="1" data-country-code="VI">Virgin Islands (U.S.) +1</option>
          <option value="84" data-country-code="VN">Vietnam +84</option>
          <option value="678" data-country-code="VU">Vanuatu +678</option>
          <option value="681" data-country-code="WF">Wallis and Futuna Islands +681</option>
          <option value="685" data-country-code="WS">Samoa +685</option>
          <option value="967" data-country-code="YE">Yemen +967</option>
          <option value="262" data-country-code="YT">Mayotte +262</option>
          <option value="27" data-country-code="ZA">South Africa +27</option>
          <option value="260" data-country-code="ZM">Zambia +260</option>
          <option value="263" data-country-code="ZW">Zimbabwe +263</option>
        </select>
      </div>
      <div class="popup-basic-booking-phone-input-container">
        <input id="popup-basic-booking-home" class="form-control popup-basic-booking-phone-input" placeholder="Home number">
        <div class="popup-basic-booking-home-icon sprite sprite-home"></div>
      </div>
    </div>
    <div class="popup-basic-booking-country-icon sprite sprite-location"></div>
  </div>
  <div class="modal-footer">
    <a href="#" class="btn btn-borderless" data-dismiss="modal">Cancel</a>
    <input type="submit" data-dismiss="modal" class="btn btn-success basic_booking_open_second_popup" value="Continue">
  </div>
</form>

POST

<form method="post">
  <div class="modal-body basic-booking-modal-body">
    <div class="alert alert-error alert-danger ml15 mr15" role="alert"></div>
    <div>
      <div class="pull-left basic-booking-reason-container select2">
        <div class="select2-container form-control popup-basic-booking-reason" id="s2id_basic_booking_reason">
          <a href="javascript:void(0)" class="select2-choice select2-default" tabindex="-1">   <span class="select2-chosen" id="select2-chosen-3">Reason of visit</span><abbr class="select2-search-choice-close"></abbr>   <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
            for="s2id_autogen3" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-3" id="s2id_autogen3">
          <div class="select2-drop select2-display-none select2-with-searchbox">
            <div class="select2-search"> <label for="s2id_autogen3_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" class="select2-input" role="combobox"
                aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-3" id="s2id_autogen3_search" placeholder=""> </div>
            <ul class="select2-results" role="listbox" id="select2-results-3"> </ul>
          </div>
        </div><select class="form-control popup-basic-booking-reason select2-init" id="basic_booking_reason" data-placeholder="Reason of visit" tabindex="-1" title="" style="display: none;">
          <option value=""></option>
          <option value="illness">Illness</option>
          <option value="consultation">Consultation</option>
          <option value="second_opinion">Second Opinion</option>
          <option value="follow_up">Follow Up</option>
          <option value="annual_check_up">Annual Check Up</option>
          <option value="pre_surgery_check_up">Pre-Surgery Check Up</option>
          <option value="travel_check_up">Travel Check Up</option>
          <option value="other">Other</option>
        </select>
      </div>
      <div class="popup-basic-booking-first-visit"> First Visit: <div class="popup-basic-booking-first-visit-radios">
          <label><input id="popup-basic-booking-radio-yes" type="radio" class="popup-basic-booking-radio" name="popup-basic-booking-radio"> Yes</label>
          <div class="popup-basic-booking-first-visit-radio-no">
            <label><input id="popup-basic-booking-radio-no" type="radio" class="popup-basic-booking-radio" name="popup-basic-booking-radio"> No</label>
          </div>
        </div>
      </div>
      <div class="clearfix"></div>
      <div class="seperator popup-basic-booking-seperator"></div>
      <div class="popup-basic-booking-days"> Preferred day for seeing the doctor: <div class="popup-basic-booking-days-checkboxes">
          <div class="popup-basic-booking-days-checkbox-container">
            <label>
              <input type="checkbox" class="popup-basic-booking-days-checkbox" value="monday">
              <span class="popup-basic-booking-days-checkbox-day">Monday</span>
            </label>
          </div>
          <div class="popup-basic-booking-days-checkbox-container">
            <label>
              <input type="checkbox" class="popup-basic-booking-days-checkbox" value="tuesday">
              <span class="popup-basic-booking-days-checkbox-day">Tuesday</span>
            </label>
          </div>
          <div class="popup-basic-booking-days-checkbox-container">
            <label>
              <input type="checkbox" class="popup-basic-booking-days-checkbox" value="wednesday">
              <span class="popup-basic-booking-days-checkbox-day">Wednesday</span>
            </label>
          </div>
          <div class="popup-basic-booking-days-checkbox-container">
            <label>
              <input type="checkbox" class="popup-basic-booking-days-checkbox" value="thursday">
              <span class="popup-basic-booking-days-checkbox-day">Thursday</span>
            </label>
          </div>
          <div class="popup-basic-booking-days-checkbox-container">
            <label>
              <input type="checkbox" class="popup-basic-booking-days-checkbox" value="friday">
              <span class="popup-basic-booking-days-checkbox-day">Friday</span>
            </label>
          </div>
          <div class="popup-basic-booking-days-checkbox-container">
            <label>
              <input type="checkbox" class="popup-basic-booking-days-checkbox" value="saturday">
              <span class="popup-basic-booking-days-checkbox-day">Saturday</span>
            </label>
          </div>
        </div>
      </div>
      <div class="popup-basic-booking-time"> Preferred time for seeing the doctor: <div class="popup-basic-booking-time-checkboxes">
          <div class="popup-basic-booking-time-checkbox-container">
            <label>
              <input type="checkbox" class="popup-basic-booking-time-checkbox" value="morning">
              <span class="popup-basic-booking-time-checkbox-time">Morning</span>
            </label>
          </div>
          <div class="popup-basic-booking-time-checkbox-container-last">
            <label>
              <input type="checkbox" class="popup-basic-booking-time-checkbox" value="afternoon">
              <span class="popup-basic-booking-time-checkbox-time">Afternoon</span>
            </label>
          </div>
          <div class="popup-basic-booking-time-checkbox-container">
            <label>
              <input type="checkbox" class="popup-basic-booking-time-checkbox" value="evening">
              <span class="popup-basic-booking-time-checkbox-time">Evening</span>
            </label>
          </div>
        </div>
      </div>
    </div>
    <div class="seperator popup-basic-booking-seperator"></div>
    <div class="popup-basic-booking-disclaimer-container">
      <div class="popup-basic-booking-disclaimer-bold"> Note: booking online is free, but you still have to pay the doctor's consultation fee. </div>
      <span class="popup-basic-booking-disclaimer-text"> Privacy notice: The information you fill here (including your name and your phone number) will be shared with the Doctor's office. </span>
    </div>
  </div>
  <div class="modal-footer">
    <a href="#" class="btn btn-borderless" data-dismiss="modal" id="basic_booking_cancel">Cancel</a>
    <input type="submit" class="btn btn-success" id="basic_booking_submit" value="Book">
  </div>
</form>

POST

<form method="post" id="landing_doctors_basic_info_form" data-etb-form="doctors_profiles/update_basic_info" data-etb-namespace="landing_doctors">
  <div class="modal-header">
    <button type="button" class="close" data-dismiss="modal" aria-hidden="true">×</button>
    <h3 class="heading_gray">Doctor Registration</h3>
  </div>
  <div class="modal-body select2" tabindex="-1">
    <div class="alert alert-danger alert-error hide fade in"></div>
    <div class="mb10 heading_gray">Where are you currently working/residing?</div>
    <input data-etb-input="" data-etb-required="" type="text" name="city" id="landing_doctors_city" class="form-control" placeholder="City"><br>
    <div class="select2-container form-control" id="s2id_landing_doctors_country">
      <a href="javascript:void(0)" class="select2-choice select2-default" tabindex="-1">   <span class="select2-chosen" id="select2-chosen-4">Country</span><abbr class="select2-search-choice-close"></abbr>   <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
        for="s2id_autogen4" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-4" id="s2id_autogen4">
      <div class="select2-drop select2-display-none select2-with-searchbox">
        <div class="select2-search"> <label for="s2id_autogen4_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" class="select2-input" role="combobox"
            aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-4" id="s2id_autogen4_search" placeholder=""> </div>
        <ul class="select2-results" role="listbox" id="select2-results-4"> </ul>
      </div>
    </div><select data-etb-input="" data-etb-required="" name="country" id="landing_doctors_country" class="form-control select2-init" placeholder="Country" tabindex="-1" title="" style="display: none;">
      <option value=""></option>
      <option value="LB">Lebanon</option>
      <option value="AD">Andorra</option>
      <option value="AE">United Arab Emirates</option>
      <option value="AF">Afghanistan</option>
      <option value="AG">Antigua and Barbuda</option>
      <option value="AI">Anguilla</option>
      <option value="AL">Albania</option>
      <option value="AM">Armenia</option>
      <option value="AN">Netherlands Antilles</option>
      <option value="AO">Angola</option>
      <option value="AR">Argentina</option>
      <option value="AS">American Samoa</option>
      <option value="AT">Austria</option>
      <option value="AU">Australia</option>
      <option value="AW">Aruba</option>
      <option value="AZ">Azerbaijan</option>
      <option value="BA">Bosnia and Herzegovina</option>
      <option value="BB">Barbados</option>
      <option value="BD">Bangladesh</option>
      <option value="BE">Belgium</option>
      <option value="BF">Burkina Faso</option>
      <option value="BG">Bulgaria</option>
      <option value="BH">Bahrain</option>
      <option value="BI">Burundi</option>
      <option value="BJ">Benin</option>
      <option value="BM">Bermuda</option>
      <option value="BN">Brunei Darussala</option>
      <option value="BO">Bolivia</option>
      <option value="BR">Brazil</option>
      <option value="BS">Bahamas</option>
      <option value="BT">Bhutan</option>
      <option value="BW">Botswana</option>
      <option value="BY">Belarus</option>
      <option value="BZ">Belize</option>
      <option value="CA">Canada</option>
      <option value="CD">Democratic Republic of Congo</option>
      <option value="CF">Central African Republic</option>
      <option value="CG">Congo</option>
      <option value="CH">Switzerland</option>
      <option value="CI">Côte d’Ivoire</option>
      <option value="CK">Cook Islands</option>
      <option value="CL">Chile</option>
      <option value="CM">Cameroon</option>
      <option value="CN">China</option>
      <option value="CO">Colombia</option>
      <option value="CR">Costa Rica</option>
      <option value="CU">Cuba</option>
      <option value="CV">Cape Verde</option>
      <option value="CY">Cyprus</option>
      <option value="CZ">Czech Republic</option>
      <option value="DE">Germany</option>
      <option value="DJ">Djibouti</option>
      <option value="DK">Denmark</option>
      <option value="DM">Dominica</option>
      <option value="DO">Dominican Republic</option>
      <option value="DZ">Algeria</option>
      <option value="EC">Ecuador</option>
      <option value="EE">Estonia</option>
      <option value="EG">Egypt</option>
      <option value="ER">Eritrea</option>
      <option value="ES">Spain</option>
      <option value="ET">Ethiopia</option>
      <option value="FI">Finland</option>
      <option value="FJ">Fiji</option>
      <option value="FK">Falkland Islands (malvinas)</option>
      <option value="FM">Micronesia, Federated States of</option>
      <option value="FO">Faroe Islands</option>
      <option value="FR">France</option>
      <option value="GA">Gabon</option>
      <option value="GB">United Kingdom</option>
      <option value="GD">Grenada</option>
      <option value="GE">Georgia</option>
      <option value="GF">French Guiana</option>
      <option value="GH">Ghana</option>
      <option value="GI">Gibraltar</option>
      <option value="GL">Greenland</option>
      <option value="GM">Gambia</option>
      <option value="GN">Guinea</option>
      <option value="GP">Guadeloupe</option>
      <option value="GQ">Equatorial Guinea</option>
      <option value="GR">Greece</option>
      <option value="GT">Guatemala</option>
      <option value="GU">Guam</option>
      <option value="GW">Guinea-Bissau</option>
      <option value="GY">Guyana</option>
      <option value="HK">Hong Kong</option>
      <option value="HN">Honduras</option>
      <option value="HR">Croatia</option>
      <option value="HT">Haiti</option>
      <option value="HU">Hungary</option>
      <option value="ID">Indonesia</option>
      <option value="IE">Ireland</option>
      <option value="IN">India</option>
      <option value="IQ">Iraq</option>
      <option value="IR">Iran (Islamic Republic of)</option>
      <option value="IS">Iceland</option>
      <option value="IT">Italy</option>
      <option value="JM">Jamaica</option>
      <option value="JO">Jordan</option>
      <option value="JP">Japan</option>
      <option value="KE">Kenya</option>
      <option value="KG">Kyrgyzstan</option>
      <option value="KH">Cambodia</option>
      <option value="KI">Kiribati</option>
      <option value="KM">Comoros</option>
      <option value="KN">Saint Kitts and Nevis</option>
      <option value="KP">Korea, D.p.r.o.</option>
      <option value="KR">Korea, Republic of</option>
      <option value="KW">Kuwait</option>
      <option value="KY">Cayman Islands</option>
      <option value="KZ">Kazakhstan</option>
      <option value="LA">Laos</option>
      <option value="LC">Saint Lucia</option>
      <option value="LI">Liechtenstein</option>
      <option value="LK">Sri Lanka</option>
      <option value="LR">Liberia</option>
      <option value="LS">Lesotho</option>
      <option value="LT">Lithuania</option>
      <option value="LU">Luxembourg</option>
      <option value="LV">Latvia</option>
      <option value="LY">Libyan Arab Jamahiriya</option>
      <option value="MA">Morocco</option>
      <option value="MC">Monaco</option>
      <option value="MD">Moldova, Republic of</option>
      <option value="ME">Montenegro</option>
      <option value="MG">Madagascar</option>
      <option value="MH">Marshall Islands</option>
      <option value="MK">Macedonia</option>
      <option value="ML">Mali</option>
      <option value="MM">Myanmar (Burma)</option>
      <option value="MN">Mongolia</option>
      <option value="MO">Macau</option>
      <option value="MP">Northern Mariana Islands</option>
      <option value="MQ">Martinique</option>
      <option value="MR">Mauritania</option>
      <option value="MS">Montserrat</option>
      <option value="MT">Malta</option>
      <option value="MU">Mauritius</option>
      <option value="MV">Maldives</option>
      <option value="MW">Malawi</option>
      <option value="MX">Mexico</option>
      <option value="MY">Malaysia</option>
      <option value="MZ">Mozambique</option>
      <option value="NA">Namibia</option>
      <option value="NC">New Caledonia</option>
      <option value="NE">Niger</option>
      <option value="NF">Norfolk Island</option>
      <option value="NG">Nigeria</option>
      <option value="NI">Nicaragua</option>
      <option value="NL">Netherlands</option>
      <option value="NO">Norway</option>
      <option value="NP">Nepal</option>
      <option value="NR">Nauru</option>
      <option value="NU">Niue</option>
      <option value="NZ">New Zealand</option>
      <option value="OM">Oman</option>
      <option value="PA">Panama</option>
      <option value="PE">Peru</option>
      <option value="PF">French Polynesia</option>
      <option value="PG">Papua New Guinea</option>
      <option value="PH">Philippines</option>
      <option value="PK">Pakistan</option>
      <option value="PL">Poland</option>
      <option value="PM">St. Pierre and Miquelon</option>
      <option value="PR">Puerto Rico</option>
      <option value="PS">Palestine</option>
      <option value="PT">Portugal</option>
      <option value="PW">Palau</option>
      <option value="PY">Paraguay</option>
      <option value="QA">Qatar</option>
      <option value="RE">Réunion</option>
      <option value="RO">Romania</option>
      <option value="RS">Serbia</option>
      <option value="RU">Russian Federation</option>
      <option value="RW">Rwanda</option>
      <option value="SA">Saudi Arabia</option>
      <option value="SB">Solomon Islands</option>
      <option value="SC">Seychelles</option>
      <option value="SD">Sudan</option>
      <option value="SE">Sweden</option>
      <option value="SG">Singapore</option>
      <option value="SH">St. Helena</option>
      <option value="SI">Slovenia</option>
      <option value="SK">Slovakia (slovak Republic)</option>
      <option value="SL">Sierra Leone</option>
      <option value="SM">San Marino</option>
      <option value="SN">Senegal</option>
      <option value="SO">Somalia</option>
      <option value="SR">Suriname</option>
      <option value="SS">South Sudan</option>
      <option value="ST">São Tomé and Príncipe</option>
      <option value="SV">El Salvador</option>
      <option value="SY">Syria</option>
      <option value="SZ">Swaziland</option>
      <option value="TC">Turks and Caicos Islands</option>
      <option value="TD">Chad</option>
      <option value="TG">Togo</option>
      <option value="TH">Thailand</option>
      <option value="TJ">Tajikistan</option>
      <option value="TK">Tokelau</option>
      <option value="TM">Turkmenistan</option>
      <option value="TN">Tunisia</option>
      <option value="TO">Tonga</option>
      <option value="TP">East Timor</option>
      <option value="TR">Turkey</option>
      <option value="TT">Trinidad and Tobago</option>
      <option value="TV">Tuvalu</option>
      <option value="TW">Taiwan, Province of China</option>
      <option value="TZ">Tanzania</option>
      <option value="UA">Ukraine</option>
      <option value="UG">Uganda</option>
      <option value="US">United States</option>
      <option value="UY">Uruguay</option>
      <option value="UZ">Uzbekistan</option>
      <option value="VA">Holy See (vatican City State)</option>
      <option value="VC">Saint Vincent and the Grenadines</option>
      <option value="VE">Venezuela</option>
      <option value="VG">Virgin Islands (British)</option>
      <option value="VI">Virgin Islands (U.S.)</option>
      <option value="VN">Vietnam</option>
      <option value="VU">Vanuatu</option>
      <option value="WF">Wallis and Futuna Islands</option>
      <option value="WS">Samoa</option>
      <option value="YE">Yemen</option>
      <option value="YT">Mayotte</option>
      <option value="ZA">South Africa</option>
      <option value="ZM">Zambia</option>
      <option value="ZW">Zimbabwe</option>
    </select><br>
    <div class="dr_profile_sep pl10 pr10"></div>
    <div class="mb10">From which university did you graduate as a Medical Doctor (MD)? And in which year did you graduate?</div>
    <input type="text" data-etb-input="" data-etb-required="" name="md_school" id="landing_doctors_md_school" class="form-control" placeholder="University/School"><br>
    <div class="select2-container form-control" id="s2id_landing_doctors_md_country">
      <a href="javascript:void(0)" class="select2-choice select2-default" tabindex="-1">   <span class="select2-chosen" id="select2-chosen-5">Country</span><abbr class="select2-search-choice-close"></abbr>   <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
        for="s2id_autogen5" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-5" id="s2id_autogen5">
      <div class="select2-drop select2-display-none select2-with-searchbox">
        <div class="select2-search"> <label for="s2id_autogen5_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" class="select2-input" role="combobox"
            aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-5" id="s2id_autogen5_search" placeholder=""> </div>
        <ul class="select2-results" role="listbox" id="select2-results-5"> </ul>
      </div>
    </div><select data-etb-input="" data-etb-required="" name="md_country" id="landing_doctors_md_country" class="form-control select2-init" placeholder="Country" tabindex="-1" title="" style="display: none;">
      <option value=""></option>
      <option value="LB">Lebanon</option>
      <option value="AD">Andorra</option>
      <option value="AE">United Arab Emirates</option>
      <option value="AF">Afghanistan</option>
      <option value="AG">Antigua and Barbuda</option>
      <option value="AI">Anguilla</option>
      <option value="AL">Albania</option>
      <option value="AM">Armenia</option>
      <option value="AN">Netherlands Antilles</option>
      <option value="AO">Angola</option>
      <option value="AR">Argentina</option>
      <option value="AS">American Samoa</option>
      <option value="AT">Austria</option>
      <option value="AU">Australia</option>
      <option value="AW">Aruba</option>
      <option value="AZ">Azerbaijan</option>
      <option value="BA">Bosnia and Herzegovina</option>
      <option value="BB">Barbados</option>
      <option value="BD">Bangladesh</option>
      <option value="BE">Belgium</option>
      <option value="BF">Burkina Faso</option>
      <option value="BG">Bulgaria</option>
      <option value="BH">Bahrain</option>
      <option value="BI">Burundi</option>
      <option value="BJ">Benin</option>
      <option value="BM">Bermuda</option>
      <option value="BN">Brunei Darussala</option>
      <option value="BO">Bolivia</option>
      <option value="BR">Brazil</option>
      <option value="BS">Bahamas</option>
      <option value="BT">Bhutan</option>
      <option value="BW">Botswana</option>
      <option value="BY">Belarus</option>
      <option value="BZ">Belize</option>
      <option value="CA">Canada</option>
      <option value="CD">Democratic Republic of Congo</option>
      <option value="CF">Central African Republic</option>
      <option value="CG">Congo</option>
      <option value="CH">Switzerland</option>
      <option value="CI">Côte d’Ivoire</option>
      <option value="CK">Cook Islands</option>
      <option value="CL">Chile</option>
      <option value="CM">Cameroon</option>
      <option value="CN">China</option>
      <option value="CO">Colombia</option>
      <option value="CR">Costa Rica</option>
      <option value="CU">Cuba</option>
      <option value="CV">Cape Verde</option>
      <option value="CY">Cyprus</option>
      <option value="CZ">Czech Republic</option>
      <option value="DE">Germany</option>
      <option value="DJ">Djibouti</option>
      <option value="DK">Denmark</option>
      <option value="DM">Dominica</option>
      <option value="DO">Dominican Republic</option>
      <option value="DZ">Algeria</option>
      <option value="EC">Ecuador</option>
      <option value="EE">Estonia</option>
      <option value="EG">Egypt</option>
      <option value="ER">Eritrea</option>
      <option value="ES">Spain</option>
      <option value="ET">Ethiopia</option>
      <option value="FI">Finland</option>
      <option value="FJ">Fiji</option>
      <option value="FK">Falkland Islands (malvinas)</option>
      <option value="FM">Micronesia, Federated States of</option>
      <option value="FO">Faroe Islands</option>
      <option value="FR">France</option>
      <option value="GA">Gabon</option>
      <option value="GB">United Kingdom</option>
      <option value="GD">Grenada</option>
      <option value="GE">Georgia</option>
      <option value="GF">French Guiana</option>
      <option value="GH">Ghana</option>
      <option value="GI">Gibraltar</option>
      <option value="GL">Greenland</option>
      <option value="GM">Gambia</option>
      <option value="GN">Guinea</option>
      <option value="GP">Guadeloupe</option>
      <option value="GQ">Equatorial Guinea</option>
      <option value="GR">Greece</option>
      <option value="GT">Guatemala</option>
      <option value="GU">Guam</option>
      <option value="GW">Guinea-Bissau</option>
      <option value="GY">Guyana</option>
      <option value="HK">Hong Kong</option>
      <option value="HN">Honduras</option>
      <option value="HR">Croatia</option>
      <option value="HT">Haiti</option>
      <option value="HU">Hungary</option>
      <option value="ID">Indonesia</option>
      <option value="IE">Ireland</option>
      <option value="IN">India</option>
      <option value="IQ">Iraq</option>
      <option value="IR">Iran (Islamic Republic of)</option>
      <option value="IS">Iceland</option>
      <option value="IT">Italy</option>
      <option value="JM">Jamaica</option>
      <option value="JO">Jordan</option>
      <option value="JP">Japan</option>
      <option value="KE">Kenya</option>
      <option value="KG">Kyrgyzstan</option>
      <option value="KH">Cambodia</option>
      <option value="KI">Kiribati</option>
      <option value="KM">Comoros</option>
      <option value="KN">Saint Kitts and Nevis</option>
      <option value="KP">Korea, D.p.r.o.</option>
      <option value="KR">Korea, Republic of</option>
      <option value="KW">Kuwait</option>
      <option value="KY">Cayman Islands</option>
      <option value="KZ">Kazakhstan</option>
      <option value="LA">Laos</option>
      <option value="LC">Saint Lucia</option>
      <option value="LI">Liechtenstein</option>
      <option value="LK">Sri Lanka</option>
      <option value="LR">Liberia</option>
      <option value="LS">Lesotho</option>
      <option value="LT">Lithuania</option>
      <option value="LU">Luxembourg</option>
      <option value="LV">Latvia</option>
      <option value="LY">Libyan Arab Jamahiriya</option>
      <option value="MA">Morocco</option>
      <option value="MC">Monaco</option>
      <option value="MD">Moldova, Republic of</option>
      <option value="ME">Montenegro</option>
      <option value="MG">Madagascar</option>
      <option value="MH">Marshall Islands</option>
      <option value="MK">Macedonia</option>
      <option value="ML">Mali</option>
      <option value="MM">Myanmar (Burma)</option>
      <option value="MN">Mongolia</option>
      <option value="MO">Macau</option>
      <option value="MP">Northern Mariana Islands</option>
      <option value="MQ">Martinique</option>
      <option value="MR">Mauritania</option>
      <option value="MS">Montserrat</option>
      <option value="MT">Malta</option>
      <option value="MU">Mauritius</option>
      <option value="MV">Maldives</option>
      <option value="MW">Malawi</option>
      <option value="MX">Mexico</option>
      <option value="MY">Malaysia</option>
      <option value="MZ">Mozambique</option>
      <option value="NA">Namibia</option>
      <option value="NC">New Caledonia</option>
      <option value="NE">Niger</option>
      <option value="NF">Norfolk Island</option>
      <option value="NG">Nigeria</option>
      <option value="NI">Nicaragua</option>
      <option value="NL">Netherlands</option>
      <option value="NO">Norway</option>
      <option value="NP">Nepal</option>
      <option value="NR">Nauru</option>
      <option value="NU">Niue</option>
      <option value="NZ">New Zealand</option>
      <option value="OM">Oman</option>
      <option value="PA">Panama</option>
      <option value="PE">Peru</option>
      <option value="PF">French Polynesia</option>
      <option value="PG">Papua New Guinea</option>
      <option value="PH">Philippines</option>
      <option value="PK">Pakistan</option>
      <option value="PL">Poland</option>
      <option value="PM">St. Pierre and Miquelon</option>
      <option value="PR">Puerto Rico</option>
      <option value="PS">Palestine</option>
      <option value="PT">Portugal</option>
      <option value="PW">Palau</option>
      <option value="PY">Paraguay</option>
      <option value="QA">Qatar</option>
      <option value="RE">Réunion</option>
      <option value="RO">Romania</option>
      <option value="RS">Serbia</option>
      <option value="RU">Russian Federation</option>
      <option value="RW">Rwanda</option>
      <option value="SA">Saudi Arabia</option>
      <option value="SB">Solomon Islands</option>
      <option value="SC">Seychelles</option>
      <option value="SD">Sudan</option>
      <option value="SE">Sweden</option>
      <option value="SG">Singapore</option>
      <option value="SH">St. Helena</option>
      <option value="SI">Slovenia</option>
      <option value="SK">Slovakia (slovak Republic)</option>
      <option value="SL">Sierra Leone</option>
      <option value="SM">San Marino</option>
      <option value="SN">Senegal</option>
      <option value="SO">Somalia</option>
      <option value="SR">Suriname</option>
      <option value="SS">South Sudan</option>
      <option value="ST">São Tomé and Príncipe</option>
      <option value="SV">El Salvador</option>
      <option value="SY">Syria</option>
      <option value="SZ">Swaziland</option>
      <option value="TC">Turks and Caicos Islands</option>
      <option value="TD">Chad</option>
      <option value="TG">Togo</option>
      <option value="TH">Thailand</option>
      <option value="TJ">Tajikistan</option>
      <option value="TK">Tokelau</option>
      <option value="TM">Turkmenistan</option>
      <option value="TN">Tunisia</option>
      <option value="TO">Tonga</option>
      <option value="TP">East Timor</option>
      <option value="TR">Turkey</option>
      <option value="TT">Trinidad and Tobago</option>
      <option value="TV">Tuvalu</option>
      <option value="TW">Taiwan, Province of China</option>
      <option value="TZ">Tanzania</option>
      <option value="UA">Ukraine</option>
      <option value="UG">Uganda</option>
      <option value="US">United States</option>
      <option value="UY">Uruguay</option>
      <option value="UZ">Uzbekistan</option>
      <option value="VA">Holy See (vatican City State)</option>
      <option value="VC">Saint Vincent and the Grenadines</option>
      <option value="VE">Venezuela</option>
      <option value="VG">Virgin Islands (British)</option>
      <option value="VI">Virgin Islands (U.S.)</option>
      <option value="VN">Vietnam</option>
      <option value="VU">Vanuatu</option>
      <option value="WF">Wallis and Futuna Islands</option>
      <option value="WS">Samoa</option>
      <option value="YE">Yemen</option>
      <option value="YT">Mayotte</option>
      <option value="ZA">South Africa</option>
      <option value="ZM">Zambia</option>
      <option value="ZW">Zimbabwe</option>
    </select><br>
    <input type="text" data-etb-input="" data-etb-required="" name="md_year" class="form-control" id="landing_doctors_md_year" placeholder="Graduation Year"><br>
    <div class="mb10">What is your medical license number?</div>
    <input type="text" data-etb-input="" data-etb-required="" name="license_number" id="landing_doctors_license_number" class="form-control" placeholder="License Number"><br>
  </div>
  <div class="modal-footer">
    <input type="submit" class="btn btn-primary" id="landing_doctors_basic_info_button" value="Submit">
  </div>
</form>

POST

<form method="post">
  <div class="modal-body" tabindex="-1">
    <div class="alert alert-danger alert-error" role="alert"></div>
    <div class="alert-success alert alert-message"></div>
    <div class="popup-age-gender-container select2">
      <div>Birthday</div>
      <div class="select2-container form-control popup-age-gender-age popup-age-gender-age-selector pull-left popup-age-gender-selector-select2-margin-right" id="s2id_register-day">
        <a href="javascript:void(0)" class="select2-choice" tabindex="-1">   <span class="select2-chosen" id="select2-chosen-6">Day</span><abbr class="select2-search-choice-close"></abbr>   <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
          for="s2id_autogen6" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-6" id="s2id_autogen6">
        <div class="select2-drop select2-display-none select2-with-searchbox">
          <div class="select2-search"> <label for="s2id_autogen6_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" class="select2-input" role="combobox"
              aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-6" id="s2id_autogen6_search" placeholder=""> </div>
          <ul class="select2-results" role="listbox" id="select2-results-6"> </ul>
        </div>
      </div><select class="form-control popup-age-gender-age popup-age-gender-age-selector pull-left popup-age-gender-selector-select2-margin-right select2-init" id="register-day" tabindex="-1" title="" style="display: none;">
        <option>Day</option>
        <option value="1">1</option>
        <option value="2">2</option>
        <option value="3">3</option>
        <option value="4">4</option>
        <option value="5">5</option>
        <option value="6">6</option>
        <option value="7">7</option>
        <option value="8">8</option>
        <option value="9">9</option>
        <option value="10">10</option>
        <option value="11">11</option>
        <option value="12">12</option>
        <option value="13">13</option>
        <option value="14">14</option>
        <option value="15">15</option>
        <option value="16">16</option>
        <option value="17">17</option>
        <option value="18">18</option>
        <option value="19">19</option>
        <option value="20">20</option>
        <option value="21">21</option>
        <option value="22">22</option>
        <option value="23">23</option>
        <option value="24">24</option>
        <option value="25">25</option>
        <option value="26">26</option>
        <option value="27">27</option>
        <option value="28">28</option>
        <option value="29">29</option>
        <option value="30">30</option>
        <option value="31">31</option>
      </select>
      <div class="select2-container form-control popup-age-gender-age-selector pull-left popup-age-gender-selector-select2-margin-right" id="s2id_register-month">
        <a href="javascript:void(0)" class="select2-choice" tabindex="-1">   <span class="select2-chosen" id="select2-chosen-7">Month</span><abbr class="select2-search-choice-close"></abbr>   <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
          for="s2id_autogen7" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-7" id="s2id_autogen7">
        <div class="select2-drop select2-display-none select2-with-searchbox">
          <div class="select2-search"> <label for="s2id_autogen7_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" class="select2-input" role="combobox"
              aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-7" id="s2id_autogen7_search" placeholder=""> </div>
          <ul class="select2-results" role="listbox" id="select2-results-7"> </ul>
        </div>
      </div><select class="form-control popup-age-gender-age-selector pull-left popup-age-gender-selector-select2-margin-right select2-init" id="register-month" tabindex="-1" title="" style="display: none;">
        <option>Month</option>
        <option value="1">Jan</option>
        <option value="2">Feb</option>
        <option value="3">Mar</option>
        <option value="4">Apr</option>
        <option value="5">May</option>
        <option value="6">Jun</option>
        <option value="7">Jul</option>
        <option value="8">Aug</option>
        <option value="9">Sep</option>
        <option value="10">Oct</option>
        <option value="11">Nov</option>
        <option value="12">Dec</option>
      </select>
      <div class="select2-container form-control popup-age-gender-age-selector last pull-left" id="s2id_register-year">
        <a href="javascript:void(0)" class="select2-choice" tabindex="-1">   <span class="select2-chosen" id="select2-chosen-8">Year</span><abbr class="select2-search-choice-close"></abbr>   <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
          for="s2id_autogen8" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-8" id="s2id_autogen8">
        <div class="select2-drop select2-display-none select2-with-searchbox">
          <div class="select2-search"> <label for="s2id_autogen8_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" class="select2-input" role="combobox"
              aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-8" id="s2id_autogen8_search" placeholder=""> </div>
          <ul class="select2-results" role="listbox" id="select2-results-8"> </ul>
        </div>
      </div><select class="form-control popup-age-gender-age-selector last pull-left select2-init" id="register-year" tabindex="-1" title="" style="display: none;">
        <option>Year</option>
        <option value="1997">1997</option>
        <option value="1996">1996</option>
        <option value="1995">1995</option>
        <option value="1994">1994</option>
        <option value="1993">1993</option>
        <option value="1992">1992</option>
        <option value="1991">1991</option>
        <option value="1990">1990</option>
        <option value="1989">1989</option>
        <option value="1988">1988</option>
        <option value="1987">1987</option>
        <option value="1986">1986</option>
        <option value="1985">1985</option>
        <option value="1984">1984</option>
        <option value="1983">1983</option>
        <option value="1982">1982</option>
        <option value="1981">1981</option>
        <option value="1980">1980</option>
        <option value="1979">1979</option>
        <option value="1978">1978</option>
        <option value="1977">1977</option>
        <option value="1976">1976</option>
        <option value="1975">1975</option>
        <option value="1974">1974</option>
        <option value="1973">1973</option>
        <option value="1972">1972</option>
        <option value="1971">1971</option>
        <option value="1970">1970</option>
        <option value="1969">1969</option>
        <option value="1968">1968</option>
        <option value="1967">1967</option>
        <option value="1966">1966</option>
        <option value="1965">1965</option>
        <option value="1964">1964</option>
        <option value="1963">1963</option>
        <option value="1962">1962</option>
        <option value="1961">1961</option>
        <option value="1960">1960</option>
        <option value="1959">1959</option>
        <option value="1958">1958</option>
        <option value="1957">1957</option>
        <option value="1956">1956</option>
        <option value="1955">1955</option>
        <option value="1954">1954</option>
        <option value="1953">1953</option>
        <option value="1952">1952</option>
        <option value="1951">1951</option>
        <option value="1950">1950</option>
        <option value="1949">1949</option>
        <option value="1948">1948</option>
        <option value="1947">1947</option>
        <option value="1946">1946</option>
        <option value="1945">1945</option>
        <option value="1944">1944</option>
        <option value="1943">1943</option>
        <option value="1942">1942</option>
        <option value="1941">1941</option>
        <option value="1940">1940</option>
        <option value="1939">1939</option>
        <option value="1938">1938</option>
        <option value="1937">1937</option>
        <option value="1936">1936</option>
        <option value="1935">1935</option>
        <option value="1934">1934</option>
        <option value="1933">1933</option>
        <option value="1932">1932</option>
        <option value="1931">1931</option>
        <option value="1930">1930</option>
        <option value="1929">1929</option>
        <option value="1928">1928</option>
        <option value="1927">1927</option>
        <option value="1926">1926</option>
        <option value="1925">1925</option>
        <option value="1924">1924</option>
        <option value="1923">1923</option>
        <option value="1922">1922</option>
        <option value="1921">1921</option>
        <option value="1920">1920</option>
        <option value="1919">1919</option>
        <option value="1918">1918</option>
        <option value="1917">1917</option>
        <option value="1916">1916</option>
        <option value="1915">1915</option>
        <option value="1914">1914</option>
        <option value="1913">1913</option>
        <option value="1912">1912</option>
        <option value="1911">1911</option>
        <option value="1910">1910</option>
        <option value="1909">1909</option>
        <option value="1908">1908</option>
        <option value="1907">1907</option>
        <option value="1906">1906</option>
        <option value="1905">1905</option>
      </select>
      <div class="sprite sprite-calendar popup-age-gender-age-icon"></div>
    </div>
    <div class="clearfix"></div>
    <br>
    <div>Gender</div>
    <br>
    <div class="btn-group popup-age-gender-gender">
      <div class="register-male-radio-btn pull-left">
        <input id="register-gender-male-radio-btn" name="gender" type="radio" value="male">
        <label for="register-gender-male-radio-btn">
          <div class="sprite sprite-ask-male pull-left"></div>
          <div class="edit-question-gender-text pull-left">Male</div>
        </label>
      </div>
      <div class="register-female-radio-btn pull-left">
        <input id="register-gender-female-radio-btn" name="gender" type="radio" value="female">
        <label for="register-gender-female-radio-btn">
          <div class="sprite sprite-ask-female pull-left"></div>
          <div class="edit-question-gender-text pull-left">Female</div>
        </label>
      </div>
    </div>
  </div>
  <div class="clearfix"></div>
  <div class="modal-footer">
    <button class="btn btn-borderless" id="register-age-gender-later" data-dismiss="modal">Later</button>
    <input type="submit" class="btn btn-success" value="Save" id="register_button_patient_age_gender">
  </div>
</form>

POST

<form method="post" id="premium_question_payment_form" data-key="pk_live_ARQvlZZOnfqEayQppHHwx3zJ" enctype="multipart/form-data">
  <div class="modal-body">
    <div class="alert alert-danger alert-error"></div>
    <div class="alert alert-danger popup-premium-payment-errors hidden"></div><br>
    <div class="container-fluid">
      <div class="row">
        <div class="col-lg-5 col-md-5 col-sm-5">
          <div class="popup-premium question-summary">
            <div class="premium-question ask-for-who-container">
              <b>You asked for:</b>
              <div class="sprite sprite-edit-question pull-right js_edit_question"></div>
              <div class="ask-for-who">
                <div class="popup-question-for-who-img popup-question-for-who center"></div>
                <div class="popup-question-for-who-text popup-question-for-who center"></div>
                <div class="clearfix"></div>
              </div>
            </div>
            <div class="popup-question question center">
              <div class="popup-question sub-title"> Your question is: </div>
              <div class="popup-question question-summary"></div>
            </div>
            <div class="premium-options">
              <div class="premium-option">
                <div class="sprite sprite-premium-option pull-left"></div>
                <div id="premium_question_summary_priority">Priority asked</div>
                <div class="clearfix"></div>
              </div><br>
              <div class="premium-option">
                <div class="sprite sprite-premium-option pull-left"></div>
                <div id="premium_question_summary_specialty"></div>
                <div class="clearfix"></div>
              </div><br>
              <div class="premium-option" id="popup_question_files">
                <div class="sprite sprite-premium-option pull-left hidden"></div>
                <div id="number_files_uploaded"></div>
                <input id="file1" type="hidden" name="file1" value="">
                <input id="file2" type="hidden" name="file2" value="">
                <div class="clearfix"></div>
              </div>
            </div>
          </div>
        </div>
        <div class="col-lg-7 col-md-7 col-sm-7 popup-premium payment">
          <div class="row">
            <div class="premium-payment-text">Payment Information</div>
            <div class="card-wrapper force-ltr"></div>
          </div>
          <div class="row popup_premium_question_payment">
            <div class="col-lg-6 col-md-6 col-sm-6 popup_payment_field name">
              <div class="popup_premium_payment_textarea mb5">
                <input id="payment_name" class="form-control" placeholder="Name" type="text" size="20" maxlength="25" data-stripe="name">
              </div>
            </div>
            <div class="col-lg-6 col-md-6 col-sm-6 popup_payment_field number">
              <div class="popup_premium_payment_textarea mb5">
                <input id="payment_card_number" class="form-control" placeholder="Card Number" type="text" size="20" maxlength="19" data-stripe="number">
              </div>
              <div class="clearfix"></div>
            </div>
          </div>
          <div class="row">
            <div class="col-lg-3 col-md-3 col-sm-3 popup_premium_payment_input_month">
              <div class="select2">
                <div class="select2-container form-control pull-left" id="s2id_popup_premium_payment_input_month">
                  <a href="javascript:void(0)" class="select2-choice select2-default" tabindex="-1">   <span class="select2-chosen" id="select2-chosen-9">Month</span><abbr class="select2-search-choice-close"></abbr>   <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
                    for="s2id_autogen9" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-9" id="s2id_autogen9">
                  <div class="select2-drop select2-display-none select2-with-searchbox">
                    <div class="select2-search"> <label for="s2id_autogen9_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" class="select2-input"
                        role="combobox" aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-9" id="s2id_autogen9_search" placeholder=""> </div>
                    <ul class="select2-results" role="listbox" id="select2-results-9"> </ul>
                  </div>
                </div><select id="popup_premium_payment_input_month" name="cvc_month" class="form-control pull-left select2-init" data-placeholder="Month" data-stripe="exp-month" tabindex="-1" title="" style="display: none;">
                  <option value=""></option>
                  <option value="01">01</option>
                  <option value="02">02</option>
                  <option value="03">03</option>
                  <option value="04">04</option>
                  <option value="05">05</option>
                  <option value="06">06</option>
                  <option value="07">07</option>
                  <option value="08">08</option>
                  <option value="09">09</option>
                  <option value="10">10</option>
                  <option value="11">11</option>
                  <option value="12">12</option>
                </select>
              </div>
            </div>
            <div class="col-lg-3 col-md-3 col-sm-3 popup_premium_payment_input_year">
              <div class="select2">
                <div class="select2-container form-control pull-left" id="s2id_popup_premium_payment_input_year">
                  <a href="javascript:void(0)" class="select2-choice select2-default" tabindex="-1">   <span class="select2-chosen" id="select2-chosen-10">Year</span><abbr class="select2-search-choice-close"></abbr>   <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
                    for="s2id_autogen10" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-10" id="s2id_autogen10">
                  <div class="select2-drop select2-display-none select2-with-searchbox">
                    <div class="select2-search"> <label for="s2id_autogen10_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" class="select2-input"
                        role="combobox" aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-10" id="s2id_autogen10_search" placeholder=""> </div>
                    <ul class="select2-results" role="listbox" id="select2-results-10"> </ul>
                  </div>
                </div><select id="popup_premium_payment_input_year" class="form-control pull-left select2-init" data-stripe="exp-year" name="cvc_year" data-placeholder="Year" tabindex="-1" title="" style="display: none;">
                  <option value=""></option>} <option value="2014">2014</option>
                  <option value="2015">2015</option>
                  <option value="2016">2016</option>
                  <option value="2017">2017</option>
                  <option value="2018">2018</option>
                  <option value="2019">2019</option>
                  <option value="2020">2020</option>
                  <option value="2021">2021</option>
                  <option value="2022">2022</option>
                  <option value="2023">2023</option>
                  <option value="2024">2024</option>
                  <option value="2025">2025</option>
                  <option value="2026">2026</option>
                  <option value="2027">2027</option>
                  <option value="2028">2028</option>
                  <option value="2029">2029</option>
                  <option value="2030">2030</option>
                </select>
              </div>
            </div>
            <div class="col-lg-6 col-md-6 col-sm-6 popup_premium_payment_textarea_cvc">
              <div class="popup_premium_payment_textarea">
                <input id="payment_cvc" class="form-control" placeholder="CVC" type="text" size="4" maxlength="3" data-stripe="cvc">
              </div>
            </div>
          </div>
          <div class="row">
            <div class="premium_question_charge"> Total Charge: <span class="premium-green-text">$6.00</span> </div>
          </div>
          <div class="row">
            <div class="footer_order_summary">
              <div class="sprite sprite-order-summary-lock-icon-small pull-left"></div>
              <div class="popup-encrypt-text">We use 256-bit secure encryption providing you a safe payment environment!</div>
              <div class="clearfix"></div>
            </div>
          </div>
        </div>
      </div>
    </div>
  </div>
  <div class="modal-footer popup_premium_question_submit_footer">
    <input type="submit" id="premium_question_submit" class="btn btn-success" value="Pay $6">
  </div>
</form>

POST

<form method="post" id="premium_question_second_opinion_payment_form" data-key="pk_live_ARQvlZZOnfqEayQppHHwx3zJ">
  <div class="modal-body popup_premium_question_second_opinion_body" tabindex="-1">
    <div class="alert alert-danger alert-error"></div>
    <div class="popup_premium_options_summary">
      <div id="popup_premium_question_second_opinion_question">
        <text class="form-control" id="premium_question_second_opinion_summary_question"></text>
      </div>
      <div class="premium-option pull-left">
        <div class="sprite sprite-premium-option pull-left"></div>
        <div id="premium_question_second_opinion_summary_priority">Priority asked</div>
      </div>
      <div class="premium-option pull-left">
        <div class="sprite sprite-premium-option pull-left"></div>
        <div id="premium_question_second_opinion_summary_specialty"></div>
      </div>
      <div class="clearfix"></div>
    </div>
    <div id="premium_question_second_opinion_payment">
      <div class="alert alert-danger popup-premium-payment-errors hidden"></div><br>
      <div class="popup_premium_sub_title_payment">Payment Information</div>
      <div class="form-row popup_premium_question_payment">
        <div class="pull-left popup_premium_question_payment_field">Card Number</div>
        <div class="popup_premium_payment_textarea">
          <input id="payment_card_number_second_opinion" placeholder="XXXX-XXXX-XXXX-XXXX" class="form-control" type="text" size="20" maxlength="16" data-stripe="number">
        </div>
        <div class="clearfix"></div>
      </div>
      <div class="form-row popup_premium_question__payment">
        <div class="pull-left popup_premium_question_payment_field">Expiry Date</div>
        <div class="pull-left popup_premium_payment_input_month select2">
          <div class="select2-container form-control pull-left" id="s2id_popup_premium_payment_input_month_second_opinion">
            <a href="javascript:void(0)" class="select2-choice select2-default" tabindex="-1">   <span class="select2-chosen" id="select2-chosen-11">Month</span><abbr class="select2-search-choice-close"></abbr>   <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
              for="s2id_autogen11" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-11" id="s2id_autogen11">
            <div class="select2-drop select2-display-none select2-with-searchbox">
              <div class="select2-search"> <label for="s2id_autogen11_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" class="select2-input" role="combobox"
                  aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-11" id="s2id_autogen11_search" placeholder=""> </div>
              <ul class="select2-results" role="listbox" id="select2-results-11"> </ul>
            </div>
          </div><select id="popup_premium_payment_input_month_second_opinion" name="cvc_month" class="form-control pull-left select2-init" data-placeholder="Month" data-stripe="exp-month" tabindex="-1" title="" style="display: none;">
            <option value=""></option>
            <option value="01">01</option>
            <option value="02">02</option>
            <option value="03">03</option>
            <option value="04">04</option>
            <option value="05">05</option>
            <option value="06">06</option>
            <option value="07">07</option>
            <option value="08">08</option>
            <option value="09">09</option>
            <option value="10">10</option>
            <option value="11">11</option>
            <option value="12">12</option>
          </select>
        </div>
        <div class="pull-left popup_premium_payment_input_year select2">
          <div class="select2-container form-control pull-left" id="s2id_popup_premium_payment_input_year_second_opinion">
            <a href="javascript:void(0)" class="select2-choice select2-default" tabindex="-1">   <span class="select2-chosen" id="select2-chosen-12">Year</span><abbr class="select2-search-choice-close"></abbr>   <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
              for="s2id_autogen12" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-12" id="s2id_autogen12">
            <div class="select2-drop select2-display-none select2-with-searchbox">
              <div class="select2-search"> <label for="s2id_autogen12_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" class="select2-input" role="combobox"
                  aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-12" id="s2id_autogen12_search" placeholder=""> </div>
              <ul class="select2-results" role="listbox" id="select2-results-12"> </ul>
            </div>
          </div><select id="popup_premium_payment_input_year_second_opinion" class="form-control pull-left select2-init" data-stripe="exp-year" name="cvc_year" data-placeholder="Year" tabindex="-1" title="" style="display: none;">
            <option value=""></option>} <option value="2014">2014</option>} <option value="2015">2015</option>} <option value="2016">2016</option>} <option value="2017">2017</option>} <option value="2018">2018</option>} <option value="2019">2019
            </option>} <option value="2020">2020</option>} <option value="2021">2021</option>} <option value="2022">2022</option>} <option value="2023">2023</option>} <option value="2024">2024</option>} <option value="2025">2025</option>} <option
              value="2026">2026</option>} <option value="2027">2027</option>} <option value="2028">2028</option>} <option value="2029">2029</option>} <option value="2030">2030</option>}
          </select>
        </div>
        <div class="pull-right">
          <div class="pull-left popup_premium_question_payment_field_cvc">CVC</div>
          <div class="popup_premium_payment_textarea">
            <input id="payment_cvc_second_opinion" class="form-control" type="text" size="4" maxlength="3" data-stripe="cvc" placeholder="XXX">
          </div>
          <div class="clearfix"></div>
        </div>
        <div class="clearfix"></div>
      </div>
    </div>
    <br>
    <div class="separator"></div>
    <br>
    <div class="footer_order_summary">
      <div class="footer_order_summary_left_section pull-left">
        <div class="sprite sprite-order-summary-lock-icon pull-left"></div> We use 256-bit secure encryption providing you a safe payment environment!
      </div>
      <div class="footer_order_summary_right_section pull-right">
        <div class="sprite sprite-order-summary-master-card-icon pull-left"></div>
        <div class="sprite sprite-order-summary-visa-icon pull-right"></div>
      </div>
      <div class="clearfix"></div>
    </div>
  </div>
  <div class="modal-footer popup_premium_question_second_opinion_footer">
    <input type="submit" id="premium_question_submit_second_opinion" class="btn btn-success" value="Pay $6">
  </div>
</form>

POST

<form method="post" id="question_feedback_form" data-etb-namespace="question_feedback" data-etb-form="questions_reviews/feedback">
  <div class="modal-body" tabindex="-1">
    <p>We strive to make sure our patients are satisfied with our answers.<br>Please let us know how we can help you:</p>
    <textarea data-etb-input="" id="feedback_form_explanation_text" placeholder="Your feedback"></textarea>
  </div>
  <div class="modal-footer">
    <a href="#" class="btn btn-borderless" data-dismiss="modal">Cancel</a>
    <input data-etb-input="" id="feedback_form_help_btn" type="submit" class="pull-right btn btn-success" value="Submit">
  </div>
</form>

POST

<form method="post" id="edit_question_form">
  <div class="modal-body" tabindex="-1">
    <textarea id="edited_question" maxlength="150"></textarea>
  </div>
  <div class="modal-footer">
    <a href="#" class="btn btn-borderless" data-dismiss="modal">Cancel</a>
    <input type="submit" class="btn btn-danger" value="Edit">
  </div>
</form>

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APPOINTMENT WITH DR.

Lebanon +961

Lebanon +961 Andorra +93 United Arab Emirates +376 Afghanistan +971 Antigua and
Barbuda +1 Anguilla +1 Albania +355 Armenia +374 Netherlands Antilles +599
Angola +244 Argentina +54 American Samoa +1 Austria +43 Australia +61 Aruba +297
Azerbaijan +994 Bosnia and Herzegovina +387 Barbados +1 Bangladesh +880 Belgium
+32 Burkina Faso +226 Bulgaria +359 Bahrain +973 Burundi +257 Benin +229 Bermuda
+1 Brunei Darussala +673 Bolivia +591 Brazil +55 Bahamas +1 Bhutan +975 Botswana
+267 Belarus +375 Belize +501 Canada +1 Democratic Republic of Congo +243
Central African Republic +236 Congo +242 Switzerland +41 Côte d’Ivoire +225 Cook
Islands +682 Chile +56 Cameroon +237 China +86 Colombia +57 Costa Rica +506 Cuba
+53 Cape Verde +238 Cyprus +357 Czech Republic +420 Germany +49 Djibouti +253
Denmark +45 Dominica +1 Dominican Republic +1809 Algeria +213 Ecuador +593
Estonia +372 Egypt +20 Eritrea +291 Spain +34 Ethiopia +251 Finland +358 Fiji
+679 Falkland Islands (malvinas) +500 Micronesia, Federated States of +691 Faroe
Islands +298 France +33 Gabon +241 United Kingdom +44 Grenada +1 Georgia +995
French Guiana +594 Ghana +233 Gibraltar +350 Greenland +299 Gambia +220 Guinea
+224 Guadeloupe +590 Equatorial Guinea +240 Greece +30 Guatemala +502 Guam +1
Guinea-Bissau +245 Guyana +592 Hong Kong +852 Honduras +504 Croatia +385 Haiti
+509 Hungary +36 Indonesia +62 Ireland +353 India +91 Iraq +964 Iran (Islamic
Republic of) +98 Iceland +354 Italy +39 Jamaica +1 Jordan +962 Japan +81 Kenya
+254 Kyrgyzstan +996 Cambodia +855 Kiribati +686 Comoros +269 Saint Kitts and
Nevis +1 Korea, D.p.r.o. +850 Korea, Republic of +82 Kuwait +965 Cayman Islands
+1 Kazakhstan +7 Laos +856 Saint Lucia +1 Liechtenstein +423 Sri Lanka +94
Liberia +231 Lesotho +266 Lithuania +370 Luxembourg +352 Latvia +371 Libyan Arab
Jamahiriya +218 Morocco +212 Monaco +377 Moldova, Republic of +373 Montenegro
+382 Madagascar +261 Marshall Islands +692 Macedonia +389 Mali +223 Myanmar
(Burma) +95 Mongolia +976 Macau +853 Northern Mariana Islands +1 Martinique +596
Mauritania +222 Montserrat +1 Malta +356 Mauritius +230 Maldives +960 Malawi
+265 Mexico +52 Malaysia +60 Mozambique +258 Namibia +264 New Caledonia +687
Niger +227 Norfolk Island +6723 Nigeria +234 Nicaragua +505 Netherlands +31
Norway +47 Nepal +977 Nauru +674 Niue +683 New Zealand +64 Oman +968 Panama +507
Peru +51 French Polynesia +689 Papua New Guinea +675 Philippines +63 Pakistan
+92 Poland +48 St. Pierre and Miquelon +508 Puerto Rico +1 Palestine +970
Portugal +351 Palau +680 Paraguay +595 Qatar +974 Réunion +262 Romania +40
Serbia +381 Russian Federation +7 Rwanda +250 Saudi Arabia +966 Solomon Islands
+677 Seychelles +248 Sudan +249 Sweden +46 Singapore +65 St. Helena +290
Slovenia +386 Slovakia (slovak Republic) +421 Sierra Leone +232 San Marino +378
Senegal +221 Somalia +252 Suriname +597 South Sudan +211 São Tomé and Príncipe
+239 El Salvador +503 Syria +963 Swaziland +268 Turks and Caicos Islands +1 Chad
+235 Togo +228 Thailand +66 Tajikistan +992 Tokelau +690 Turkmenistan +993
Tunisia +216 Tonga +676 East Timor +670 Turkey +90 Trinidad and Tobago +1 Tuvalu
+688 Taiwan, Province of China +886 Tanzania +255 Ukraine +380 Uganda +256
United States +1 Uruguay +598 Uzbekistan +998 Holy See (vatican City State) +379
Saint Vincent and the Grenadines +1 Venezuela +58 Virgin Islands (British) +84
Virgin Islands (U.S.) +1 Vietnam +84 Vanuatu +678 Wallis and Futuna Islands +681
Samoa +685 Yemen +967 Mayotte +262 South Africa +27 Zambia +260 Zimbabwe +263


Lebanon +961

Lebanon +961 Andorra +93 United Arab Emirates +376 Afghanistan +971 Antigua and
Barbuda +1 Anguilla +1 Albania +355 Armenia +374 Netherlands Antilles +599
Angola +244 Argentina +54 American Samoa +1 Austria +43 Australia +61 Aruba +297
Azerbaijan +994 Bosnia and Herzegovina +387 Barbados +1 Bangladesh +880 Belgium
+32 Burkina Faso +226 Bulgaria +359 Bahrain +973 Burundi +257 Benin +229 Bermuda
+1 Brunei Darussala +673 Bolivia +591 Brazil +55 Bahamas +1 Bhutan +975 Botswana
+267 Belarus +375 Belize +501 Canada +1 Democratic Republic of Congo +243
Central African Republic +236 Congo +242 Switzerland +41 Côte d’Ivoire +225 Cook
Islands +682 Chile +56 Cameroon +237 China +86 Colombia +57 Costa Rica +506 Cuba
+53 Cape Verde +238 Cyprus +357 Czech Republic +420 Germany +49 Djibouti +253
Denmark +45 Dominica +1 Dominican Republic +1809 Algeria +213 Ecuador +593
Estonia +372 Egypt +20 Eritrea +291 Spain +34 Ethiopia +251 Finland +358 Fiji
+679 Falkland Islands (malvinas) +500 Micronesia, Federated States of +691 Faroe
Islands +298 France +33 Gabon +241 United Kingdom +44 Grenada +1 Georgia +995
French Guiana +594 Ghana +233 Gibraltar +350 Greenland +299 Gambia +220 Guinea
+224 Guadeloupe +590 Equatorial Guinea +240 Greece +30 Guatemala +502 Guam +1
Guinea-Bissau +245 Guyana +592 Hong Kong +852 Honduras +504 Croatia +385 Haiti
+509 Hungary +36 Indonesia +62 Ireland +353 India +91 Iraq +964 Iran (Islamic
Republic of) +98 Iceland +354 Italy +39 Jamaica +1 Jordan +962 Japan +81 Kenya
+254 Kyrgyzstan +996 Cambodia +855 Kiribati +686 Comoros +269 Saint Kitts and
Nevis +1 Korea, D.p.r.o. +850 Korea, Republic of +82 Kuwait +965 Cayman Islands
+1 Kazakhstan +7 Laos +856 Saint Lucia +1 Liechtenstein +423 Sri Lanka +94
Liberia +231 Lesotho +266 Lithuania +370 Luxembourg +352 Latvia +371 Libyan Arab
Jamahiriya +218 Morocco +212 Monaco +377 Moldova, Republic of +373 Montenegro
+382 Madagascar +261 Marshall Islands +692 Macedonia +389 Mali +223 Myanmar
(Burma) +95 Mongolia +976 Macau +853 Northern Mariana Islands +1 Martinique +596
Mauritania +222 Montserrat +1 Malta +356 Mauritius +230 Maldives +960 Malawi
+265 Mexico +52 Malaysia +60 Mozambique +258 Namibia +264 New Caledonia +687
Niger +227 Norfolk Island +6723 Nigeria +234 Nicaragua +505 Netherlands +31
Norway +47 Nepal +977 Nauru +674 Niue +683 New Zealand +64 Oman +968 Panama +507
Peru +51 French Polynesia +689 Papua New Guinea +675 Philippines +63 Pakistan
+92 Poland +48 St. Pierre and Miquelon +508 Puerto Rico +1 Palestine +970
Portugal +351 Palau +680 Paraguay +595 Qatar +974 Réunion +262 Romania +40
Serbia +381 Russian Federation +7 Rwanda +250 Saudi Arabia +966 Solomon Islands
+677 Seychelles +248 Sudan +249 Sweden +46 Singapore +65 St. Helena +290
Slovenia +386 Slovakia (slovak Republic) +421 Sierra Leone +232 San Marino +378
Senegal +221 Somalia +252 Suriname +597 South Sudan +211 São Tomé and Príncipe
+239 El Salvador +503 Syria +963 Swaziland +268 Turks and Caicos Islands +1 Chad
+235 Togo +228 Thailand +66 Tajikistan +992 Tokelau +690 Turkmenistan +993
Tunisia +216 Tonga +676 East Timor +670 Turkey +90 Trinidad and Tobago +1 Tuvalu
+688 Taiwan, Province of China +886 Tanzania +255 Ukraine +380 Uganda +256
United States +1 Uruguay +598 Uzbekistan +998 Holy See (vatican City State) +379
Saint Vincent and the Grenadines +1 Venezuela +58 Virgin Islands (British) +84
Virgin Islands (U.S.) +1 Vietnam +84 Vanuatu +678 Wallis and Futuna Islands +681
Samoa +685 Yemen +967 Mayotte +262 South Africa +27 Zambia +260 Zimbabwe +263


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APPOINTMENT WITH DR.

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DOCTOR REGISTRATION

Where are you currently working/residing?

Country

LebanonAndorraUnited Arab EmiratesAfghanistanAntigua and
BarbudaAnguillaAlbaniaArmeniaNetherlands AntillesAngolaArgentinaAmerican
SamoaAustriaAustraliaArubaAzerbaijanBosnia and
HerzegovinaBarbadosBangladeshBelgiumBurkina
FasoBulgariaBahrainBurundiBeninBermudaBrunei
DarussalaBoliviaBrazilBahamasBhutanBotswanaBelarusBelizeCanadaDemocratic
Republic of CongoCentral African RepublicCongoSwitzerlandCôte d’IvoireCook
IslandsChileCameroonChinaColombiaCosta RicaCubaCape VerdeCyprusCzech
RepublicGermanyDjiboutiDenmarkDominicaDominican
RepublicAlgeriaEcuadorEstoniaEgyptEritreaSpainEthiopiaFinlandFijiFalkland
Islands (malvinas)Micronesia, Federated States ofFaroe IslandsFranceGabonUnited
KingdomGrenadaGeorgiaFrench
GuianaGhanaGibraltarGreenlandGambiaGuineaGuadeloupeEquatorial
GuineaGreeceGuatemalaGuamGuinea-BissauGuyanaHong
KongHondurasCroatiaHaitiHungaryIndonesiaIrelandIndiaIraqIran (Islamic Republic
of)IcelandItalyJamaicaJordanJapanKenyaKyrgyzstanCambodiaKiribatiComorosSaint
Kitts and NevisKorea, D.p.r.o.Korea, Republic ofKuwaitCayman
IslandsKazakhstanLaosSaint LuciaLiechtensteinSri
LankaLiberiaLesothoLithuaniaLuxembourgLatviaLibyan Arab
JamahiriyaMoroccoMonacoMoldova, Republic ofMontenegroMadagascarMarshall
IslandsMacedoniaMaliMyanmar (Burma)MongoliaMacauNorthern Mariana
IslandsMartiniqueMauritaniaMontserratMaltaMauritiusMaldivesMalawiMexicoMalaysiaMozambiqueNamibiaNew
CaledoniaNigerNorfolk IslandNigeriaNicaraguaNetherlandsNorwayNepalNauruNiueNew
ZealandOmanPanamaPeruFrench PolynesiaPapua New
GuineaPhilippinesPakistanPolandSt. Pierre and MiquelonPuerto
RicoPalestinePortugalPalauParaguayQatarRéunionRomaniaSerbiaRussian
FederationRwandaSaudi ArabiaSolomon IslandsSeychellesSudanSwedenSingaporeSt.
HelenaSloveniaSlovakia (slovak Republic)Sierra LeoneSan
MarinoSenegalSomaliaSurinameSouth SudanSão Tomé and PríncipeEl
SalvadorSyriaSwazilandTurks and Caicos
IslandsChadTogoThailandTajikistanTokelauTurkmenistanTunisiaTongaEast
TimorTurkeyTrinidad and TobagoTuvaluTaiwan, Province of
ChinaTanzaniaUkraineUgandaUnited StatesUruguayUzbekistanHoly See (vatican City
State)Saint Vincent and the GrenadinesVenezuelaVirgin Islands (British)Virgin
Islands (U.S.)VietnamVanuatuWallis and Futuna IslandsSamoaYemenMayotteSouth
AfricaZambiaZimbabwe


From which university did you graduate as a Medical Doctor (MD)? And in which
year did you graduate?

Country

LebanonAndorraUnited Arab EmiratesAfghanistanAntigua and
BarbudaAnguillaAlbaniaArmeniaNetherlands AntillesAngolaArgentinaAmerican
SamoaAustriaAustraliaArubaAzerbaijanBosnia and
HerzegovinaBarbadosBangladeshBelgiumBurkina
FasoBulgariaBahrainBurundiBeninBermudaBrunei
DarussalaBoliviaBrazilBahamasBhutanBotswanaBelarusBelizeCanadaDemocratic
Republic of CongoCentral African RepublicCongoSwitzerlandCôte d’IvoireCook
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