{"id":12959,"date":"2021-04-29T20:52:52","date_gmt":"2021-04-29T20:52:52","guid":{"rendered":"https:\/\/clone.arsacs.com\/?page_id=12959"},"modified":"2026-07-30T10:17:09","modified_gmt":"2026-07-30T14:17:09","slug":"registrarsi","status":"publish","type":"page","link":"https:\/\/arsacs.com\/it\/register\/","title":{"rendered":"Registrati"},"content":{"rendered":"<div class=\"et_pb_section_0 et_pb_section et_section_regular et_block_section\">\n<div class=\"et_pb_row_0 et_pb_row et_block_row\">\n<div class=\"et_pb_column_0 et_pb_column et_pb_column_4_4 et-last-child et_block_column et_pb_css_mix_blend_mode_passthrough\">\n<div class=\"et_pb_text_0 et_pb_text et_pb_bg_layout_light et_pb_module et_block_module\"><div class=\"et_pb_text_inner\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Register a Patient Diagnosed with ARSACS<\/h2>\n                            <p class='gform_description'><p>This is an easy and simple on-line registry. Please fill out the form to subscribe to the International ARSACS Patient Registry. All fields marked with (*) are required.<\/p>\r\n<p><strong>You must have legal authority to provide personal information concerning another person<\/strong><\/p><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indica i campi obbligatori<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/it\/wp-json\/wp\/v2\/pages\/12959#gf_1' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_18\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Identification of person entering the data<\/h3><\/div><fieldset id=\"field_1_1\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>The diagnosed ARSACS person that I am registering is<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_1'>\n\t\t\t<div class='gchoice gchoice_1_1_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_1' type='radio' value='myself (18 years or older)'  id='choice_1_1_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_1_0' id='label_1_1_0' class='gform-field-label gform-field-label--type-inline'>myself (18 years or older)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_1_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_1' type='radio' value='a person for whom I have legal authority to consent to having his \/ her personal information entered in the register (eg, a parent, a guardian).'  id='choice_1_1_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_1_1' id='label_1_1_1' class='gform-field-label gform-field-label--type-inline'>a person for whom I have legal authority to consent to having his \/ her personal information entered in the register (eg, a parent, a guardian).<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <button type='button' id='gform_next_button_1_41' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-41' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_38\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Contact information for person entering the data<\/h3><\/div><fieldset id=\"field_1_19\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Your Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_19'>\n                            \n                            <span id='input_1_19_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_19.3' id='input_1_19_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_19_3' class='gform-field-label gform-field-label--type-sub '>Nome<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_19_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_19.6' id='input_1_19_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_19_6' class='gform-field-label gform-field-label--type-sub '>Cognome<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_1_50\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Your Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_1_50' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_50_1_container' >\n                                        <input type='text' name='input_50.1' id='input_1_50_1' value=''    aria-required='true'    \/>\n                                        <label for='input_1_50_1' id='input_1_50_1_label' class='gform-field-label gform-field-label--type-sub '>Via\/Piazza\/Corso e numero civico<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_50_3_container' >\n                                    <input type='text' name='input_50.3' id='input_1_50_3' value=''    aria-required='true'    \/>\n                                    <label for='input_1_50_3' id='input_1_50_3_label' class='gform-field-label gform-field-label--type-sub '>Localit\u00e0<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_50_4_container' >\n                                        <input type='text' name='input_50.4' id='input_1_50_4' value=''      aria-required='true'    \/>\n                                        <label for='input_1_50_4' id='input_1_50_4_label' class='gform-field-label gform-field-label--type-sub '>Stato \/ Provincia \/ Regione<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_50_5_container' >\n                                    <input type='text' name='input_50.5' id='input_1_50_5' value=''    aria-required='true'    \/>\n                                    <label for='input_1_50_5' id='input_1_50_5_label' class='gform-field-label gform-field-label--type-sub '>CAP \/ Codice postale<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_50_6_container' >\n                                        <select name='input_50.6' id='input_1_50_6'   aria-required='true'    ><option value='' ><\/option><option value='AF' >Afghanistan<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antartide<\/option><option value='AG' >Antigua e Barbuda<\/option><option value='SA' >Arabia Saudita<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BE' >Belgio<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BY' >Bielorussia<\/option><option value='MM' >Birmania<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius e Saba<\/option><option value='BA' >Bosnia-Erzegovina<\/option><option value='BW' >Botswana<\/option><option value='BR' >Brasile<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambogia<\/option><option value='CM' >Camerun<\/option><option value='CA' >Canada<\/option><option value='CV' >Capo Verde<\/option><option value='TD' >Chad<\/option><option value='CL' >Cile<\/option><option value='CN' >Cina<\/option><option value='CY' >Cipro<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comore<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Repubblica Democratica del<\/option><option value='KP' >Corea, (Repubblica Democratica Popolare di)<\/option><option value='KR' >Corea, Repubblica di<\/option><option value='CR' >Costa Rica<\/option><option value='CI' >Costa d&#039;Avorio<\/option><option value='HR' >Croazia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='DK' >Danimarca<\/option><option value='DM' >Dominica<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egitto<\/option><option value='SV' >El Salvador<\/option><option value='AE' >Emirati Arabi Uniti<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='ET' >Etiopia<\/option><option value='RU' >Federazione Russa<\/option><option value='FJ' >Fiji<\/option><option value='PH' >Filippine<\/option><option value='FI' >Finlandia<\/option><option value='FR' >Francia<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germania<\/option><option value='GH' >Ghana<\/option><option value='JM' >Giamaica<\/option><option value='JP' >Giappone<\/option><option value='GI' >Gibilterra<\/option><option value='DJ' >Gibuti<\/option><option value='JO' >Giordania<\/option><option value='GR' >Grecia<\/option><option value='GD' >Grenada<\/option><option value='GL' >Groenlandia<\/option><option value='GP' >Guadalupa<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GF' >Guiana Francese<\/option><option value='GN' >Guinea<\/option><option value='GQ' >Guinea Equatoriale<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Irlanda<\/option><option value='IS' >Islanda<\/option><option value='BV' >Isola di Bouvet<\/option><option value='IM' >Isola di Man<\/option><option value='CX' >Isola di Natale<\/option><option value='BL' >Isola di Saint Barth\u00e9lemy<\/option><option value='AX' >Isole Aland<\/option><option value='KY' >Isole Cayman<\/option><option value='CC' >Isole Cocos<\/option><option value='CK' >Isole Cook<\/option><option value='FK' >Isole Falkland<\/option><option value='FO' >Isole Faroe<\/option><option value='HM' >Isole Heard e McDonald<\/option><option value='MP' >Isole Marianne Settentrionali<\/option><option value='MH' >Isole Marshall<\/option><option value='NF' >Isole Norfolk<\/option><option value='PM' >Isole Saint Pierre e Miquelon<\/option><option value='SB' >Isole Salomone<\/option><option value='SJ' >Isole Svalbard e Jan Mayen<\/option><option value='TC' >Isole Turks e Caicos<\/option><option value='VG' >Isole Vergini britanniche<\/option><option value='UM' >Isole minori esterne degli Stati Uniti d&#039;America<\/option><option value='VI' >Isole vergini americane<\/option><option value='IL' >Israele<\/option><option value='IT' >Italia<\/option><option value='GS' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='KZ' >Kazakistan<\/option><option value='KE' >Kenya<\/option><option value='KG' >Kirghizistan<\/option><option value='KI' >Kiribati<\/option><option value='KW' >Kuwait<\/option><option value='LA' >Laos<\/option><option value='LS' >Lesotho<\/option><option value='LV' >Lettonia<\/option><option value='LB' >Libano<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libia<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lituania<\/option><option value='LU' >Lussemburgo<\/option><option value='MO' >Macao<\/option><option value='MK' >Macedonia del Nord<\/option><option value='MG' >Madagascar<\/option><option value='JE' >Maglia<\/option><option value='MW' >Malawi<\/option><option value='MV' >Maldive<\/option><option value='MY' >Malesia<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MA' >Marocco<\/option><option value='MQ' >Martinica<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Messico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldavia<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MZ' >Mozambico<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NO' >Norvegia<\/option><option value='NC' >Nuova Caledonia<\/option><option value='NZ' >Nuova Zelanda<\/option><option value='OM' >Oman<\/option><option value='NL' >Paesi Bassi<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua Nuova Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Polonia<\/option><option value='PF' >Polynesia Francese<\/option><option value='PR' >Porto Rico<\/option><option value='PT' >Portogallo<\/option><option value='QA' >Qatar<\/option><option value='GB' >Regno Unito<\/option><option value='SY' >Repubblica Araba di Siria<\/option><option value='CZ' >Repubblica Ceca<\/option><option value='CF' >Repubblica Centrafricana<\/option><option value='DO' >Repubblica Dominicana<\/option><option value='RE' >Riunione (Isola della)<\/option><option value='RO' >Romania<\/option><option value='RW' >Ruanda<\/option><option value='EH' >Sahara Occidentale<\/option><option value='KN' >Saint Kitts e Nevis<\/option><option value='VC' >Saint Vincent e Grenadine<\/option><option value='MF' >Saint-Martin<\/option><option value='WS' >Samoa<\/option><option value='AS' >Samoa americane<\/option><option value='SM' >San Marino<\/option><option value='SH' >Sant&#039;Elena, Ascensione e Tristan da Cunha<\/option><option value='LC' >Santa Lucia<\/option><option value='ST' >Sao Tome e Pr\u00edncipe<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SX' >Sint Maarten<\/option><option value='SK' >Slovacchia<\/option><option value='SI' >Slovenia<\/option><option value='SO' >Somalia<\/option><option value='ES' >Spagna<\/option><option value='LK' >Sri Lanka<\/option><option value='US' >Stati Uniti<\/option><option value='PS' >Stato della Palestina<\/option><option value='ZA' >Sudafrica<\/option><option value='SD' >Sudan<\/option><option value='SS' >Sudan del Sud<\/option><option value='SR' >Suriname<\/option><option value='SE' >Svezia<\/option><option value='CH' >Svizzera<\/option><option value='TJ' >Tagikistan<\/option><option value='TW' >Taiwan<\/option><option value='TZ' >Tanzania (Repubblica Unita della)<\/option><option value='TF' >Territori Meridionali Francesi<\/option><option value='IO' >Territorio Britannico nell&#039;Oceano Indiano<\/option><option value='TH' >Thailandia<\/option><option value='TL' >Timor Est<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad e Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turchia<\/option><option value='TM' >Turkmenistan<\/option><option value='TV' >Tuvalu<\/option><option value='UA' >Ucraina<\/option><option value='UG' >Uganda<\/option><option value='HU' >Ungheria<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vaticano (Santa Sede)<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis e Futuna<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><option value='SZ' >eSwatini<\/option><\/select>\n                                        <label for='input_1_50_6' id='input_1_50_6_label' class='gform-field-label gform-field-label--type-sub '>Nazione<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_1_21\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Your Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_1_21'>Registration confirmation will be sent to this email address.<\/div><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_1_21_container'>\n                                <span id='input_1_21_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_21' id='input_1_21' value=''    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_1_21\" \/>\n                                    <label for='input_1_21' class='gform-field-label gform-field-label--type-sub '>Enter Email Address<\/label>\n                                <\/span>\n                                <span id='input_1_21_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_21_2' id='input_1_21_2' value=''    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_1_21\" \/>\n                                    <label for='input_1_21_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email Address<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><fieldset id=\"field_1_36\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Second Email (optional)<\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_1_36_container'>\n                                <span id='input_1_36_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_36' id='input_1_36' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_1_36' class='gform-field-label gform-field-label--type-sub '>Enter 2nd Email<\/label>\n                                <\/span>\n                                <span id='input_1_36_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_36_2' id='input_1_36_2' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_1_36_2' class='gform-field-label gform-field-label--type-sub '>Confirm 2nd Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_1_22\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_22'><span class='gform-field-label__text'>Your Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_22' id='input_1_22' type='tel' value='' class='medium'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_1_23\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_23'><span class='gform-field-label__text'>Relationship with the ARSACS patient who has the authority to consent for that person<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_1_23' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Parent' >Parent<\/option><option value='Guardian' >Guardian<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_1_42' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_1_42' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-42' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_9\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Patient Information<\/h3><\/div><fieldset id=\"field_1_2\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_2'>\n                            \n                            <span id='input_1_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_1_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_2_3' class='gform-field-label gform-field-label--type-sub '>Nome<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_1_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_2_6' class='gform-field-label gform-field-label--type-sub '>Cognome<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon dob gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'><span class='gform-field-label__text'>Date of Birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='aaaa\/mm\/gg'\n\t\t\t\t\tid='input_1_3'\n\t\t\t\t\tclass='datepicker gform-datepicker ymd_slash datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_3'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"9999\/99\/99\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_1_3' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_1_3' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_1_3' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_1_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Gender<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_6'>\n\t\t\t<div class='gchoice gchoice_1_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Male'  id='choice_1_6_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_6_0' id='label_1_6_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Female'  id='choice_1_6_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_6_1' id='label_1_6_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_1_45' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_1_45' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-45' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_46\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Patient is under 18 years old<\/h3><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'><span class='gform-field-label__text'>Name of Parent\/Guardian<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_1_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_47\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Patient Contact Information<\/h3><\/div><fieldset id=\"field_1_10\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_1_10' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_10_1_container' >\n                                        <input type='text' name='input_10.1' id='input_1_10_1' value=''    aria-required='true'    \/>\n                                        <label for='input_1_10_1' id='input_1_10_1_label' class='gform-field-label gform-field-label--type-sub '>Via\/Piazza\/Corso e numero civico<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_10_2_container' >\n                                        <input type='text' name='input_10.2' id='input_1_10_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_10_2' id='input_1_10_2_label' class='gform-field-label gform-field-label--type-sub '>Indirizzo riga 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_10_3_container' >\n                                    <input type='text' name='input_10.3' id='input_1_10_3' value=''    aria-required='true'    \/>\n                                    <label for='input_1_10_3' id='input_1_10_3_label' class='gform-field-label gform-field-label--type-sub '>Localit\u00e0<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_10_4_container' >\n                                        <input type='text' name='input_10.4' id='input_1_10_4' value=''      aria-required='true'    \/>\n                                        <label for='input_1_10_4' id='input_1_10_4_label' class='gform-field-label gform-field-label--type-sub '>Stato \/ Provincia \/ Regione<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_10_5_container' >\n                                    <input type='text' name='input_10.5' id='input_1_10_5' value=''    aria-required='true'    \/>\n                                    <label for='input_1_10_5' id='input_1_10_5_label' class='gform-field-label gform-field-label--type-sub '>CAP \/ Codice postale<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_10_6_container' >\n                                        <select name='input_10.6' id='input_1_10_6'   aria-required='true'    ><option value='' ><\/option><option value='AF' >Afghanistan<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antartide<\/option><option value='AG' >Antigua e Barbuda<\/option><option value='SA' >Arabia Saudita<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BE' >Belgio<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BY' >Bielorussia<\/option><option value='MM' >Birmania<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius e Saba<\/option><option value='BA' >Bosnia-Erzegovina<\/option><option value='BW' >Botswana<\/option><option value='BR' >Brasile<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambogia<\/option><option value='CM' >Camerun<\/option><option value='CA' >Canada<\/option><option value='CV' >Capo Verde<\/option><option value='TD' >Chad<\/option><option value='CL' >Cile<\/option><option value='CN' >Cina<\/option><option value='CY' >Cipro<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comore<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Repubblica Democratica del<\/option><option value='KP' >Corea, (Repubblica Democratica Popolare di)<\/option><option value='KR' >Corea, Repubblica di<\/option><option value='CR' >Costa Rica<\/option><option value='CI' >Costa d&#039;Avorio<\/option><option value='HR' >Croazia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='DK' >Danimarca<\/option><option value='DM' >Dominica<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egitto<\/option><option value='SV' >El Salvador<\/option><option value='AE' >Emirati Arabi Uniti<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='ET' >Etiopia<\/option><option value='RU' >Federazione Russa<\/option><option value='FJ' >Fiji<\/option><option value='PH' >Filippine<\/option><option value='FI' >Finlandia<\/option><option value='FR' >Francia<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germania<\/option><option value='GH' >Ghana<\/option><option value='JM' >Giamaica<\/option><option value='JP' >Giappone<\/option><option value='GI' >Gibilterra<\/option><option value='DJ' >Gibuti<\/option><option value='JO' >Giordania<\/option><option value='GR' >Grecia<\/option><option value='GD' >Grenada<\/option><option value='GL' >Groenlandia<\/option><option value='GP' >Guadalupa<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GF' >Guiana Francese<\/option><option value='GN' >Guinea<\/option><option value='GQ' >Guinea Equatoriale<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Irlanda<\/option><option value='IS' >Islanda<\/option><option value='BV' >Isola di Bouvet<\/option><option value='IM' >Isola di Man<\/option><option value='CX' >Isola di Natale<\/option><option value='BL' >Isola di Saint Barth\u00e9lemy<\/option><option value='AX' >Isole Aland<\/option><option value='KY' >Isole Cayman<\/option><option value='CC' >Isole Cocos<\/option><option value='CK' >Isole Cook<\/option><option value='FK' >Isole Falkland<\/option><option value='FO' >Isole Faroe<\/option><option value='HM' >Isole Heard e McDonald<\/option><option value='MP' >Isole Marianne Settentrionali<\/option><option value='MH' >Isole Marshall<\/option><option value='NF' >Isole Norfolk<\/option><option value='PM' >Isole Saint Pierre e Miquelon<\/option><option value='SB' >Isole Salomone<\/option><option value='SJ' >Isole Svalbard e Jan Mayen<\/option><option value='TC' >Isole Turks e Caicos<\/option><option value='VG' >Isole Vergini britanniche<\/option><option value='UM' >Isole minori esterne degli Stati Uniti d&#039;America<\/option><option value='VI' >Isole vergini americane<\/option><option value='IL' >Israele<\/option><option value='IT' >Italia<\/option><option value='GS' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='KZ' >Kazakistan<\/option><option value='KE' >Kenya<\/option><option value='KG' >Kirghizistan<\/option><option value='KI' >Kiribati<\/option><option value='KW' >Kuwait<\/option><option value='LA' >Laos<\/option><option value='LS' >Lesotho<\/option><option value='LV' >Lettonia<\/option><option value='LB' >Libano<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libia<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lituania<\/option><option value='LU' >Lussemburgo<\/option><option value='MO' >Macao<\/option><option value='MK' >Macedonia del Nord<\/option><option value='MG' >Madagascar<\/option><option value='JE' >Maglia<\/option><option value='MW' >Malawi<\/option><option value='MV' >Maldive<\/option><option value='MY' >Malesia<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MA' >Marocco<\/option><option value='MQ' >Martinica<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Messico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldavia<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MZ' >Mozambico<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NO' >Norvegia<\/option><option value='NC' >Nuova Caledonia<\/option><option value='NZ' >Nuova Zelanda<\/option><option value='OM' >Oman<\/option><option value='NL' >Paesi Bassi<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua Nuova Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Polonia<\/option><option value='PF' >Polynesia Francese<\/option><option value='PR' >Porto Rico<\/option><option value='PT' >Portogallo<\/option><option value='QA' >Qatar<\/option><option value='GB' >Regno Unito<\/option><option value='SY' >Repubblica Araba di Siria<\/option><option value='CZ' >Repubblica Ceca<\/option><option value='CF' >Repubblica Centrafricana<\/option><option value='DO' >Repubblica Dominicana<\/option><option value='RE' >Riunione (Isola della)<\/option><option value='RO' >Romania<\/option><option value='RW' >Ruanda<\/option><option value='EH' >Sahara Occidentale<\/option><option value='KN' >Saint Kitts e Nevis<\/option><option value='VC' >Saint Vincent e Grenadine<\/option><option value='MF' >Saint-Martin<\/option><option value='WS' >Samoa<\/option><option value='AS' >Samoa americane<\/option><option value='SM' >San Marino<\/option><option value='SH' >Sant&#039;Elena, Ascensione e Tristan da Cunha<\/option><option value='LC' >Santa Lucia<\/option><option value='ST' >Sao Tome e Pr\u00edncipe<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SX' >Sint Maarten<\/option><option value='SK' >Slovacchia<\/option><option value='SI' >Slovenia<\/option><option value='SO' >Somalia<\/option><option value='ES' >Spagna<\/option><option value='LK' >Sri Lanka<\/option><option value='US' >Stati Uniti<\/option><option value='PS' >Stato della Palestina<\/option><option value='ZA' >Sudafrica<\/option><option value='SD' >Sudan<\/option><option value='SS' >Sudan del Sud<\/option><option value='SR' >Suriname<\/option><option value='SE' >Svezia<\/option><option value='CH' >Svizzera<\/option><option value='TJ' >Tagikistan<\/option><option value='TW' >Taiwan<\/option><option value='TZ' >Tanzania (Repubblica Unita della)<\/option><option value='TF' >Territori Meridionali Francesi<\/option><option value='IO' >Territorio Britannico nell&#039;Oceano Indiano<\/option><option value='TH' >Thailandia<\/option><option value='TL' >Timor Est<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad e Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turchia<\/option><option value='TM' >Turkmenistan<\/option><option value='TV' >Tuvalu<\/option><option value='UA' >Ucraina<\/option><option value='UG' >Uganda<\/option><option value='HU' >Ungheria<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vaticano (Santa Sede)<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis e Futuna<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><option value='SZ' >eSwatini<\/option><\/select>\n                                        <label for='input_1_10_6' id='input_1_10_6_label' class='gform-field-label gform-field-label--type-sub '>Nazione<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_1_7\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_1_7_container'>\n                                <span id='input_1_7_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_7' id='input_1_7' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_1_7' class='gform-field-label gform-field-label--type-sub '>Enter Email Address<\/label>\n                                <\/span>\n                                <span id='input_1_7_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_7_2' id='input_1_7_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_1_7_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email Address<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><fieldset id=\"field_1_37\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Second Email (optional)<\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_1_37_container'>\n                                <span id='input_1_37_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_37' id='input_1_37' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_1_37' class='gform-field-label gform-field-label--type-sub '>(optional)<\/label>\n                                <\/span>\n                                <span id='input_1_37_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_37_2' id='input_1_37_2' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_1_37_2' class='gform-field-label gform-field-label--type-sub '>Confirm 2nd Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_1_11\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'><span class='gform-field-label__text'>Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_1_11' type='tel' value='' class='medium'    aria-invalid=\"false\"    \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_1_43' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_1_43' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_5' class='gform_page' data-js='page-field-id-43' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_5' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_12\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Doctor Information (optional)<\/h3><\/div><div id=\"field_1_13\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_13'><span class='gform-field-label__text'>Name of doctor of the ARSACS patient<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_49\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_49'><span class='gform-field-label__text'>Doctor&#039;s Email<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_49' id='input_1_49' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_1_14\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address of Doctor\/Clinic where patient received diagnosis<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_1_14' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_14_1_container' >\n                                        <input type='text' name='input_14.1' id='input_1_14_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_14_1' id='input_1_14_1_label' class='gform-field-label gform-field-label--type-sub '>Via\/Piazza\/Corso e numero civico<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_14_2_container' >\n                                        <input type='text' name='input_14.2' id='input_1_14_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_14_2' id='input_1_14_2_label' class='gform-field-label gform-field-label--type-sub '>Indirizzo riga 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_14_3_container' >\n                                    <input type='text' name='input_14.3' id='input_1_14_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_14_3' id='input_1_14_3_label' class='gform-field-label gform-field-label--type-sub '>Localit\u00e0<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_14_4_container' >\n                                        <input type='text' name='input_14.4' id='input_1_14_4' value=''      aria-required='false'    \/>\n                                        <label for='input_1_14_4' id='input_1_14_4_label' class='gform-field-label gform-field-label--type-sub '>Stato \/ Provincia \/ Regione<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_14_5_container' >\n                                    <input type='text' name='input_14.5' id='input_1_14_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_14_5' id='input_1_14_5_label' class='gform-field-label gform-field-label--type-sub '>CAP \/ Codice postale<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_14_6_container' >\n                                        <select name='input_14.6' id='input_1_14_6'   aria-required='false'    ><option value='' ><\/option><option value='AF' >Afghanistan<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antartide<\/option><option value='AG' >Antigua e Barbuda<\/option><option value='SA' >Arabia Saudita<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BE' >Belgio<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BY' >Bielorussia<\/option><option value='MM' >Birmania<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius e Saba<\/option><option value='BA' >Bosnia-Erzegovina<\/option><option value='BW' >Botswana<\/option><option value='BR' >Brasile<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambogia<\/option><option value='CM' >Camerun<\/option><option value='CA' >Canada<\/option><option value='CV' >Capo Verde<\/option><option value='TD' >Chad<\/option><option value='CL' >Cile<\/option><option value='CN' >Cina<\/option><option value='CY' >Cipro<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comore<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Repubblica Democratica del<\/option><option value='KP' >Corea, (Repubblica Democratica Popolare di)<\/option><option value='KR' >Corea, Repubblica di<\/option><option value='CR' >Costa Rica<\/option><option value='CI' >Costa d&#039;Avorio<\/option><option value='HR' >Croazia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='DK' >Danimarca<\/option><option value='DM' >Dominica<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egitto<\/option><option value='SV' >El Salvador<\/option><option value='AE' >Emirati Arabi Uniti<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='ET' >Etiopia<\/option><option value='RU' >Federazione Russa<\/option><option value='FJ' >Fiji<\/option><option value='PH' >Filippine<\/option><option value='FI' >Finlandia<\/option><option value='FR' >Francia<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germania<\/option><option value='GH' >Ghana<\/option><option value='JM' >Giamaica<\/option><option value='JP' >Giappone<\/option><option value='GI' >Gibilterra<\/option><option value='DJ' >Gibuti<\/option><option value='JO' >Giordania<\/option><option value='GR' >Grecia<\/option><option value='GD' >Grenada<\/option><option value='GL' >Groenlandia<\/option><option value='GP' >Guadalupa<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GF' >Guiana Francese<\/option><option value='GN' >Guinea<\/option><option value='GQ' >Guinea Equatoriale<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Irlanda<\/option><option value='IS' >Islanda<\/option><option value='BV' >Isola di Bouvet<\/option><option value='IM' >Isola di Man<\/option><option value='CX' >Isola di Natale<\/option><option value='BL' >Isola di Saint Barth\u00e9lemy<\/option><option value='AX' >Isole Aland<\/option><option value='KY' >Isole Cayman<\/option><option value='CC' >Isole Cocos<\/option><option value='CK' >Isole Cook<\/option><option value='FK' >Isole Falkland<\/option><option value='FO' >Isole Faroe<\/option><option value='HM' >Isole Heard e McDonald<\/option><option value='MP' >Isole Marianne Settentrionali<\/option><option value='MH' >Isole Marshall<\/option><option value='NF' >Isole Norfolk<\/option><option value='PM' >Isole Saint Pierre e Miquelon<\/option><option value='SB' >Isole Salomone<\/option><option value='SJ' >Isole Svalbard e Jan Mayen<\/option><option value='TC' >Isole Turks e Caicos<\/option><option value='VG' >Isole Vergini britanniche<\/option><option value='UM' >Isole minori esterne degli Stati Uniti d&#039;America<\/option><option value='VI' >Isole vergini americane<\/option><option value='IL' >Israele<\/option><option value='IT' >Italia<\/option><option value='GS' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='KZ' >Kazakistan<\/option><option value='KE' >Kenya<\/option><option value='KG' >Kirghizistan<\/option><option value='KI' >Kiribati<\/option><option value='KW' >Kuwait<\/option><option value='LA' >Laos<\/option><option value='LS' >Lesotho<\/option><option value='LV' >Lettonia<\/option><option value='LB' >Libano<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libia<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lituania<\/option><option value='LU' >Lussemburgo<\/option><option value='MO' >Macao<\/option><option value='MK' >Macedonia del Nord<\/option><option value='MG' >Madagascar<\/option><option value='JE' >Maglia<\/option><option value='MW' >Malawi<\/option><option value='MV' >Maldive<\/option><option value='MY' >Malesia<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MA' >Marocco<\/option><option value='MQ' >Martinica<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Messico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldavia<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MZ' >Mozambico<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NO' >Norvegia<\/option><option value='NC' >Nuova Caledonia<\/option><option value='NZ' >Nuova Zelanda<\/option><option value='OM' >Oman<\/option><option value='NL' >Paesi Bassi<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua Nuova Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Polonia<\/option><option value='PF' >Polynesia Francese<\/option><option value='PR' >Porto Rico<\/option><option value='PT' >Portogallo<\/option><option value='QA' >Qatar<\/option><option value='GB' >Regno Unito<\/option><option value='SY' >Repubblica Araba di Siria<\/option><option value='CZ' >Repubblica Ceca<\/option><option value='CF' >Repubblica Centrafricana<\/option><option value='DO' >Repubblica Dominicana<\/option><option value='RE' >Riunione (Isola della)<\/option><option value='RO' >Romania<\/option><option value='RW' >Ruanda<\/option><option value='EH' >Sahara Occidentale<\/option><option value='KN' >Saint Kitts e Nevis<\/option><option value='VC' >Saint Vincent e Grenadine<\/option><option value='MF' >Saint-Martin<\/option><option value='WS' >Samoa<\/option><option value='AS' >Samoa americane<\/option><option value='SM' >San Marino<\/option><option value='SH' >Sant&#039;Elena, Ascensione e Tristan da Cunha<\/option><option value='LC' >Santa Lucia<\/option><option value='ST' >Sao Tome e Pr\u00edncipe<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SX' >Sint Maarten<\/option><option value='SK' >Slovacchia<\/option><option value='SI' >Slovenia<\/option><option value='SO' >Somalia<\/option><option value='ES' >Spagna<\/option><option value='LK' >Sri Lanka<\/option><option value='US' >Stati Uniti<\/option><option value='PS' >Stato della Palestina<\/option><option value='ZA' >Sudafrica<\/option><option value='SD' >Sudan<\/option><option value='SS' >Sudan del Sud<\/option><option value='SR' >Suriname<\/option><option value='SE' >Svezia<\/option><option value='CH' >Svizzera<\/option><option value='TJ' >Tagikistan<\/option><option value='TW' >Taiwan<\/option><option value='TZ' >Tanzania (Repubblica Unita della)<\/option><option value='TF' >Territori Meridionali Francesi<\/option><option value='IO' >Territorio Britannico nell&#039;Oceano Indiano<\/option><option value='TH' >Thailandia<\/option><option value='TL' >Timor Est<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad e Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turchia<\/option><option value='TM' >Turkmenistan<\/option><option value='TV' >Tuvalu<\/option><option value='UA' >Ucraina<\/option><option value='UG' >Uganda<\/option><option value='HU' >Ungheria<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vaticano (Santa Sede)<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis e Futuna<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><option value='SZ' >eSwatini<\/option><\/select>\n                                        <label for='input_1_14_6' id='input_1_14_6_label' class='gform-field-label gform-field-label--type-sub '>Nazione<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_1_44' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_1_44' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_6' class='gform_page' data-js='page-field-id-44' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_6' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_15\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below 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