{"id":9782,"date":"2025-12-26T12:00:35","date_gmt":"2025-12-26T03:00:35","guid":{"rendered":"https:\/\/mrclinic.tokyo\/en\/?page_id=9782"},"modified":"2025-12-26T15:04:16","modified_gmt":"2025-12-26T06:04:16","slug":"regenerative-treatment-questionnaire","status":"publish","type":"page","link":"https:\/\/mrclinic.tokyo\/en\/regenerative-treatment-questionnaire\/","title":{"rendered":"Regenerative Treatment Questionnaire"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"9782\" class=\"elementor elementor-9782\">\n\t\t\t\t<div class=\"elementor-element elementor-element-26ba0410 e-flex e-con-boxed e-con e-parent\" data-id=\"26ba0410\" data-element_type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-5f01e542 e-con-full e-flex e-con e-child\" data-id=\"5f01e542\" data-element_type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3373f6c7 elementor-widget elementor-widget-spacer\" data-id=\"3373f6c7\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-44490ad5 elementor-widget elementor-widget-heading\" data-id=\"44490ad5\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Regenerative Treatment Questionnaire<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-45b9dc4 elementor-widget elementor-widget-spacer\" data-id=\"45b9dc4\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-31f039f elementor-widget elementor-widget-text-editor\" data-id=\"31f039f\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>For those interested in regenerative medicine, please fill out and submit the questionnaire before your consultation. By sharing your situation in advance, this will help shorten the consultation time and contribute to a more in-depth and productive session.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-5e50ce7f elementor-widget elementor-widget-text-editor\" data-id=\"5e50ce7f\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>\u203bDisclaimer: This form is used to collect information about patients and used for internal purposes only. The information you supply is confidential and will be treated accordingly.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-35403296 elementor-widget elementor-widget-spacer\" data-id=\"35403296\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-ae583e2 e-flex e-con-boxed e-con e-parent\" data-id=\"ae583e2\" data-element_type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-be52bb6 e-con-full e-flex e-con e-child\" data-id=\"be52bb6\" data-element_type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3b1fcfa elementor-widget elementor-widget-contact-form-7\" data-id=\"3b1fcfa\" data-element_type=\"widget\" data-widget_type=\"contact-form-7.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-contact-form-7 jet-elements\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f9284-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"9284\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/9782#wpcf7-f9284-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"9284\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f9284-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"mrc-contact-form\">\n\t<p><span class=\"part required\">Date of Entry\uff1a<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-entry-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"your-entry-date\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"part\">Your Information<\/span><br \/>\n<span class=\"required\">Name <\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span><\/span><br \/>\n<span class=\"required\">Gender <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-gender\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"your-gender\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"your-gender\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><\/span><\/span> <\/span><br \/>\n<span class=\"required\">Date of Birth <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-birthday\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"your-birthday\" \/><\/span><\/span><span> (<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-age\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length2\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"your-age\" \/><\/span><\/span><span> years old)<\/span><br \/>\n<span class=\"required\">Nationality <\/span><span> <span class=\"wpcf7-form-control-wrap\" data-name=\"your-nationality\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-nationality\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span>Height <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-height\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length2\" min=\"0\" max=\"999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"your-height\" \/><\/span><\/span><span>cm<\/span><span>Weight <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-weight\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length2\" min=\"0\" max=\"999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"your-weight\" \/><\/span><\/span><span>kg<\/span>\n\t<\/p>\n\t<p><span class=\"required\">Address<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-address\" \/><\/span><br \/>\n<span class=\"required\">Phone Number <\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-phonenumber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"your-phonenumber\" \/><\/span><br \/>\n<span class=\"required\">Email Address <\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n\t<\/p>\n\t<p><span class=\"part\">Concerns you want to improve <\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"want-improve\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"want-improve[]\" value=\"Pain\" \/><span class=\"wpcf7-list-item-label\">Pain<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"want-improve[]\" value=\"Diabete\" \/><span class=\"wpcf7-list-item-label\">Diabete<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"want-improve[]\" value=\"Liver function\" \/><span class=\"wpcf7-list-item-label\">Liver function<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"want-improve[]\" value=\"Kidney function\" \/><span class=\"wpcf7-list-item-label\">Kidney function<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"want-improve[]\" value=\"Sexual function\" \/><span class=\"wpcf7-list-item-label\">Sexual function<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"want-improve[]\" value=\"Beauty (skin\/hair growth)\" \/><span class=\"wpcf7-list-item-label\">Beauty (skin\/hair growth)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"want-improve[]\" value=\"Prevention of cognitive decline\" \/><span class=\"wpcf7-list-item-label\">Prevention of cognitive decline<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"want-improve-other\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"want-improve-other[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"want-improve-other-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"want-improve-other-text\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"part\">Treatment performed at another hospital <\/span><br \/>\n<span class=\"section required\">Surgery<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-surgery\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-surgery\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-surgery\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"\">Year <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-surgery-year\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length4\" min=\"1000\" max=\"9999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"treatment-another-hospital-surgery-year\" \/><\/span><\/span><span class=\"\">Location <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-surgery-location\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"treatment-another-hospital-surgery-location\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"section required\">Anti-aging <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-antiaging\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-antiaging-items\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging-items[]\" value=\"Fillers\" \/><span class=\"wpcf7-list-item-label\">Fillers<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging-items[]\" value=\"Botox\" \/><span class=\"wpcf7-list-item-label\">Botox<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging-items[]\" value=\"Peeling\" \/><span class=\"wpcf7-list-item-label\">Peeling<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging-items[]\" value=\"Thread lift\" \/><span class=\"wpcf7-list-item-label\">Thread lift<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging-items[]\" value=\"Laser\" \/><span class=\"wpcf7-list-item-label\">Laser<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging-items[]\" value=\"Liposuction\" \/><span class=\"wpcf7-list-item-label\">Liposuction<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"section required\">Regenerative Medicine <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"\">When did the receive the treatment?<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-when\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"treatment-another-hospital-regenerative-when\" \/><\/span><\/span><br \/>\n<span class=\"\">Treatment <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-treatment\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative-treatment[]\" value=\"PRP\" \/><span class=\"wpcf7-list-item-label\">PRP<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative-treatment[]\" value=\"APS\" \/><span class=\"wpcf7-list-item-label\">APS<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative-treatment[]\" value=\"FGF\" \/><span class=\"wpcf7-list-item-label\">FGF<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative-treatment[]\" value=\"ACRS\" \/><span class=\"wpcf7-list-item-label\">ACRS<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative-treatment[]\" value=\"Supernatant fluid treatment\" \/><span class=\"wpcf7-list-item-label\">Supernatant fluid treatment<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative-treatment[]\" value=\"Stem cell therapy\" \/><span class=\"wpcf7-list-item-label\">Stem cell therapy<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"\">Where was the treated?<\/span><br \/>\n<span class=\"\">Country <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-country\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"treatment-another-hospital-regenerative-country\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Dubai(UAE)\">Dubai(UAE)<\/option><option value=\"Korea\">Korea<\/option><option value=\"Malaysia\">Malaysia<\/option><option value=\"Mexico\">Mexico<\/option><option value=\"Thailand\">Thailand<\/option><option value=\"Ukraine\">Ukraine<\/option><option value=\"Japan\">Japan<\/option><option value=\"Other\">Other<\/option><\/select><\/span><\/span><span class=\"\"> Other<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-country-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"treatment-another-hospital-regenerative-country-other\" \/><\/span><\/span><br \/>\n<span class=\"\">Area <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-area\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"treatment-another-hospital-regenerative-area\" \/><\/span><\/span><span class=\"\"> Clinic Name <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-clinic\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"treatment-another-hospital-regenerative-clinic\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"\">Please provide details about your stem cell therapy (if applicable)<\/span><br \/>\n<span class=\"\">Administration method <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-stemcell-method\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative-stemcell-method[]\" value=\"IV infusion\" \/><span class=\"wpcf7-list-item-label\">IV infusion<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative-stemcell-method[]\" value=\"local injection\" \/><span class=\"wpcf7-list-item-label\">local injection<\/span><\/label><\/span><\/span><\/span><\/span><span class=\"\"> Injection site <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-stemcell-injectionsite\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"treatment-another-hospital-regenerative-stemcell-injectionsite\" \/><\/span><\/span><br \/>\n<span class=\"\">Number of administrations <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-stemcell-administrations-count\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length4\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"treatment-another-hospital-regenerative-stemcell-administrations-count\" \/><\/span><\/span><span>times<\/span><br \/>\n<span class=\"\">Number of cells administered <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-stemcell-cells-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"treatment-another-hospital-regenerative-stemcell-cells-number\" \/><\/span><\/span><br \/>\n<span class=\"\">Effectiveness <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-stemcell-effectiveness\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"treatment-another-hospital-regenerative-stemcell-effectiveness\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Good\">Good<\/option><option value=\"Poor\">Poor<\/option><option value=\"No Change\">No Change<\/option><\/select><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"required\">Pain treatment <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-pain\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-pain\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-pain\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-pain-detail\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-pain-detail[]\" value=\"Chiropractic\" \/><span class=\"wpcf7-list-item-label\">Chiropractic<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-pain-detail[]\" value=\"Acupuncture\" \/><span class=\"wpcf7-list-item-label\">Acupuncture<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-pain-detail[]\" value=\"Massage\" \/><span class=\"wpcf7-list-item-label\">Massage<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-pain-detail[]\" value=\"Injection\" \/><span class=\"wpcf7-list-item-label\">Injection<\/span><\/label><\/span><\/span><\/span><\/span><span class=\"heading\">Other\uff1a<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-at-another-hospital-pain-detail-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"treatment-at-another-hospital-pain-detail-other\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"required\">Data from Other Hospitals <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"data-from-other-hospitals\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"data-from-other-hospitals-items\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"Medical Certificate\" \/><span class=\"wpcf7-list-item-label\">Medical Certificate<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"Treatment Progress Record\" \/><span class=\"wpcf7-list-item-label\">Treatment Progress Record<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"Blood Test Results\" \/><span class=\"wpcf7-list-item-label\">Blood Test Results<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"X-ray\" \/><span class=\"wpcf7-list-item-label\">X-ray<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"CT Scan\" \/><span class=\"wpcf7-list-item-label\">CT Scan<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"MRI\" \/><span class=\"wpcf7-list-item-label\">MRI<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"PET Scan\" \/><span class=\"wpcf7-list-item-label\">PET Scan<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"Surgical Record\" \/><span class=\"wpcf7-list-item-label\">Surgical Record<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"Radiation Therapy Record\" \/><span class=\"wpcf7-list-item-label\">Radiation Therapy Record<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"Chemotherapy Record\" \/><span class=\"wpcf7-list-item-label\">Chemotherapy Record<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"\">If you have medical records from another hospital, please upload them here.<\/span><br \/>\n<span class=\"\">Attachment file <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"data-from-other-hospitals-uploadfile\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpeg,.jpg,.png,.gif,.bmp,.pdf\" aria-invalid=\"false\" type=\"file\" name=\"data-from-other-hospitals-uploadfile\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"heading\">Other <\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-other\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"treatment-another-hospital-other\"><\/textarea><\/span>\n\t<\/p>\n\t<p><span class=\"section required\">Illness under treatment <\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"under-treatment\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"None\" \/><span class=\"wpcf7-list-item-label\">None<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"High blood pressure\" \/><span class=\"wpcf7-list-item-label\">High blood pressure<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"Diabetes\" \/><span class=\"wpcf7-list-item-label\">Diabetes<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"Liver disorder\" \/><span class=\"wpcf7-list-item-label\">Liver disorder<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"Kidney disorder\" \/><span class=\"wpcf7-list-item-label\">Kidney disorder<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"Heart disease\" \/><span class=\"wpcf7-list-item-label\">Heart disease<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"Cerebral\" \/><span class=\"wpcf7-list-item-label\">Cerebral<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"Hemorrhage\/Cerebral infarction\" \/><span class=\"wpcf7-list-item-label\">Hemorrhage\/Cerebral infarction<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"Asthma\/COPD\" \/><span class=\"wpcf7-list-item-label\">Asthma\/COPD<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"Immune disease\" \/><span class=\"wpcf7-list-item-label\">Immune disease<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"Malignant tumor\" \/><span class=\"wpcf7-list-item-label\">Malignant tumor<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"Mental disease\" \/><span class=\"wpcf7-list-item-label\">Mental disease<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"Infertility\" \/><span class=\"wpcf7-list-item-label\">Infertility<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"required\">Treatment of infectious diseases <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"under-treatment-infectious\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"under-treatment-infectious\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"under-treatment-infectious\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"\">If yes, which of the following infectious diseases are you being treated for? (Select all that apply)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"under-treatment-infectious-items\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"under-treatment-infectious-items[]\" value=\"Hepatitis (Type A)\" \/><span class=\"wpcf7-list-item-label\">Hepatitis (Type A)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment-infectious-items[]\" value=\"Hepatitis (Type B)\" \/><span class=\"wpcf7-list-item-label\">Hepatitis (Type B)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment-infectious-items[]\" value=\"Hepatitis (Type C)\" \/><span class=\"wpcf7-list-item-label\">Hepatitis (Type C)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment-infectious-items[]\" value=\"Tuberculosis\" \/><span class=\"wpcf7-list-item-label\">Tuberculosis<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment-infectious-items[]\" value=\"Syphilis\" \/><span class=\"wpcf7-list-item-label\">Syphilis<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment-infectious-items[]\" value=\"HIV\/AIDS\" \/><span class=\"wpcf7-list-item-label\">HIV\/AIDS<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"under-treatment-infectious-items[]\" value=\"HTLV\u22121\" \/><span class=\"wpcf7-list-item-label\">HTLV\u22121<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"section\">Current Medications\/Supplements <\/span><br \/>\nIf yes, please list the medications you're taking, including the name and dosage(amount of active ingredient e.g. mg).<br \/>\n<span class=\"required\">Blood thinners <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-supplements-blood-thinners\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"current-medications-supplements-blood-thinners\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-medications-supplements-blood-thinners\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-supplements-blood-thinners-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"current-medications-supplements-blood-thinners-text\" \/><\/span><\/span><br \/>\n<span class=\"required\">Blood thinning supplements <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-supplements-blood-thinning-supplements\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"current-medications-supplements-blood-thinning-supplements\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-medications-supplements-blood-thinning-supplements\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-supplements-blood-thinning-supplements-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"current-medications-supplements-blood-thinning-supplements-text\" \/><\/span><\/span><br \/>\n<span class=\"required\">Hypertension medications <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-hypertension-medications\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"current-medications-hypertension-medications\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-medications-hypertension-medications\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-hypertension-medications-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"current-medications-hypertension-medications-text\" \/><\/span><\/span><br \/>\n<span class=\"required\">Diabetes medications <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-diabetes-medications\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"current-medications-diabetes-medications\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-medications-diabetes-medications\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-diabetes-medications-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"current-medications-diabetes-medications-text\" \/><\/span><\/span><br \/>\n<span class=\"required\">Female hormone therapy <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-female-hormone-therapy\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"current-medications-female-hormone-therapy\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-medications-female-hormone-therapy\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-female-hormone-therapy-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"current-medications-female-hormone-therapy-text\" \/><\/span><\/span><br \/>\n<span class=\"required\">Psychiatric medications <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-psychiatric-medications\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"current-medications-psychiatric-medications\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-medications-psychiatric-medications\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-psychiatric-medications-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"current-medications-psychiatric-medications-text\" \/><\/span><\/span><br \/>\n<span class=\"\">Others <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-others-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"current-medications-others-text\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"part\">Social History<\/span><br \/>\n<span class=\"section required\">Alcohol <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"social-history-alcohol\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"social-history-alcohol\" value=\"Do not drink\" \/><span class=\"wpcf7-list-item-label\">Do not drink<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"social-history-alcohol\" value=\"Drink\" \/><span class=\"wpcf7-list-item-label\">Drink<\/span><\/label><\/span><\/span><\/span><\/span><span>( <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"social-history-alcohol-amount\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"social-history-alcohol-amount\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"1 cup of sake\">1 cup of sake<\/option><option value=\"1 large bottle of beer\">1 large bottle of beer<\/option><option value=\"2\/3 cup of shochu\/awamori\">2\/3 cup of shochu\/awamori<\/option><option value=\"1 double shot of whiskey\">1 double shot of whiskey<\/option><option value=\"1\/3 bottle of wine\">1\/3 bottle of wine<\/option><option value=\"Drink more than this amount\">Drink more than this amount<\/option><\/select><\/span><\/span><span> )<\/span><br \/>\n<span class=\"section required\">Tobacco <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"social-history-tobacco\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"social-history-tobacco\" value=\"Do not smoke\" \/><span class=\"wpcf7-list-item-label\">Do not smoke<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"social-history-tobacco\" value=\"Smoke\" \/><span class=\"wpcf7-list-item-label\">Smoke<\/span><\/label><\/span><\/span><\/span><\/span><span> (<\/span><span> <span class=\"wpcf7-form-control-wrap\" data-name=\"social-history-tobacco-amount\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length2\" min=\"0\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"social-history-tobacco-amount\" \/><\/span><\/span><span> cigarettes\/day )<\/span>\n\t<\/p>\n\t<p><span class=\"part\">Medical History<\/span><br \/>\n<span class=\"section\">Allergies <\/span><br \/>\n<span class=\"subsection required\">Food <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-food\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"None\" \/><span class=\"wpcf7-list-item-label\">None<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Kiwi\" \/><span class=\"wpcf7-list-item-label\">Kiwi<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Banana\" \/><span class=\"wpcf7-list-item-label\">Banana<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Avocado\" \/><span class=\"wpcf7-list-item-label\">Avocado<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Papaya\" \/><span class=\"wpcf7-list-item-label\">Papaya<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Mango\" \/><span class=\"wpcf7-list-item-label\">Mango<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Melon\" \/><span class=\"wpcf7-list-item-label\">Melon<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Fig\" \/><span class=\"wpcf7-list-item-label\">Fig<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Cherry\" \/><span class=\"wpcf7-list-item-label\">Cherry<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Egg\" \/><span class=\"wpcf7-list-item-label\">Egg<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Soy\" \/><span class=\"wpcf7-list-item-label\">Soy<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Wheat\" \/><span class=\"wpcf7-list-item-label\">Wheat<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Peanuts\" \/><span class=\"wpcf7-list-item-label\">Peanuts<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Blue fish (e.g., mackerel, sardine)\" \/><span class=\"wpcf7-list-item-label\">Blue fish (e.g., mackerel, sardine)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"indent10\">If you selected \"Other,\" please specify the food.<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-food-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"allergies-food-other\" \/><\/span><\/span><br \/>\n<span class=\"\">Severity of Allergic Reaction <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-food-severity\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-food-severity\" value=\"Mild\" \/><span class=\"wpcf7-list-item-label\">Mild<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food-severity\" value=\"Moderate\" \/><span class=\"wpcf7-list-item-label\">Moderate<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-food-severity\" value=\"Severe\" \/><span class=\"wpcf7-list-item-label\">Severe<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">Medication <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-medication\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"None\" \/><span class=\"wpcf7-list-item-label\">None<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"Aspirin (e.g., Bufferin)\" \/><span class=\"wpcf7-list-item-label\">Aspirin (e.g., Bufferin)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"Ibuprofen (e.g., Brufen, Eve)\" \/><span class=\"wpcf7-list-item-label\">Ibuprofen (e.g., Brufen, Eve)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"Loxoprofen (e.g., Loxonin)\" \/><span class=\"wpcf7-list-item-label\">Loxoprofen (e.g., Loxonin)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"Anesthetics (e.g., Xylocaine)\" \/><span class=\"wpcf7-list-item-label\">Anesthetics (e.g., Xylocaine)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"\">If you selected \"Other,\" please specify the medication. <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-medication-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"allergies-medication-other\" \/><\/span><\/span><br \/>\n<span class=\"\">Severity of Allergic Reaction<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-medication-severity\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-medication-severity\" value=\"Mild\" \/><span class=\"wpcf7-list-item-label\">Mild<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication-severity\" value=\"Moderate\" \/><span class=\"wpcf7-list-item-label\">Moderate<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-medication-severity\" value=\"Severe\" \/><span class=\"wpcf7-list-item-label\">Severe<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">Antibiotics\/Antifungals <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-antibiotics\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"None\" \/><span class=\"wpcf7-list-item-label\">None<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"Penicillin antibiotics\" \/><span class=\"wpcf7-list-item-label\">Penicillin antibiotics<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"Cephalosporins (e.g., Cefzon)\" \/><span class=\"wpcf7-list-item-label\">Cephalosporins (e.g., Cefzon)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"Streptomycin\" \/><span class=\"wpcf7-list-item-label\">Streptomycin<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"Amikacin\" \/><span class=\"wpcf7-list-item-label\">Amikacin<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"Aminoglycosides (excluding streptomycin, amikacin)\" \/><span class=\"wpcf7-list-item-label\">Aminoglycosides (excluding streptomycin, amikacin)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"Amphotericin B\" \/><span class=\"wpcf7-list-item-label\">Amphotericin B<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span> <\/span><br \/>\n<span class=\"\">If you selected \"Other,\" please specify the medication. <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-antibiotics-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"allergies-antibiotics-other\" \/><\/span><\/span><br \/>\n<span class=\"\">Severity of Allergic Reaction <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-antibiotics-severity\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-antibiotics-severity\" value=\"Mild\" \/><span class=\"wpcf7-list-item-label\">Mild<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics-severity\" value=\"Moderate\" \/><span class=\"wpcf7-list-item-label\">Moderate<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-antibiotics-severity\" value=\"Severe\" \/><span class=\"wpcf7-list-item-label\">Severe<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">Other <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-other\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-other[]\" value=\"None\" \/><span class=\"wpcf7-list-item-label\">None<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-other[]\" value=\"Latex\" \/><span class=\"wpcf7-list-item-label\">Latex<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-other[]\" value=\"Alcohol\" \/><span class=\"wpcf7-list-item-label\">Alcohol<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-other[]\" value=\"Iodine\" \/><span class=\"wpcf7-list-item-label\">Iodine<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"\">Severity of Allergic Reaction <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-other-severity\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-other-severity\" value=\"Mild\" \/><span class=\"wpcf7-list-item-label\">Mild<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-other-severity\" value=\"Moderate\" \/><span class=\"wpcf7-list-item-label\">Moderate<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-other-severity\" value=\"Severe\" \/><span class=\"wpcf7-list-item-label\">Severe<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"section required\">Have you ever felt sick from anesthesia such as dental anesthesia (xylocaine) or gastroscopy?<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"anesthesia\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"anesthesia\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"anesthesia\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"section required\">Are you pregnant or at risk of pregnancy (miscarriage or bortion within the last 3 months)?<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"pregnancy\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"pregnancy\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"pregnancy\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"part\">Emergency Contact<\/span><br \/>\n<span>Name<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-ec-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-ec-name\" \/><\/span><br \/>\n<span>Phone Number<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-ec-phone-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"your-ec-phone-number\" \/><\/span><br \/>\n<span>Email Address<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-ec-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-ec-email\" \/><\/span><br \/>\n<span>Relationship with Patient<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-ec-relationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-ec-relationship\" \/><\/span>\n\t<\/p>\n\t<p><span class=\"part\">Additional Notes <\/span><span>Please include any additional information that may be relevant to your overall health condition<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"additional-notes\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"additional-notes\"><\/textarea><\/span>\n\t<\/p>\n\t<p><span class=\"part\">Source Questions<\/span><br \/>\n<span class=\"section required\">Please select the purpose of your inquiry.<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"purpose-of-your-inquiry\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"Make an appointment\" \/><span class=\"wpcf7-list-item-label\">Make an appointment<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"Ask about consultation and treatment\" \/><span class=\"wpcf7-list-item-label\">Ask about consultation and treatment<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"Inquire about fees and payment\" \/><span class=\"wpcf7-list-item-label\">Inquire about fees and payment<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"Ask about other matters\" \/><span class=\"wpcf7-list-item-label\">Ask about other matters<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"Need immediate treatment\" \/><span class=\"wpcf7-list-item-label\">Need immediate treatment<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"section required\">How did you hear about our clinic?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"how-about-our-clinic\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"Friend&#039;s referral\" \/><span class=\"wpcf7-list-item-label\">Friend&#039;s referral<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"Agent&#039;s referral\" \/><span class=\"wpcf7-list-item-label\">Agent&#039;s referral<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"Attended seminar\" \/><span class=\"wpcf7-list-item-label\">Attended seminar<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"Saw website\" \/><span class=\"wpcf7-list-item-label\">Saw website<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"Instagram\" \/><span class=\"wpcf7-list-item-label\">Instagram<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"Facebook\" \/><span class=\"wpcf7-list-item-label\">Facebook<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"WeChat\" \/><span class=\"wpcf7-list-item-label\">WeChat<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><br \/>\n<span>If you select other, please specify how you found out about the clinic, and It would be helpful if you could provide the name of friend or agent who referred you.<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"how-about-our-clinic-other\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"how-about-our-clinic-other\"><\/textarea><\/span><br \/>\nThank you very much for your cooperation.<br \/>\n<div class=\"cf7-cf-turnstile\" style=\"margin-top: 0px; margin-bottom: -15px;\"> <div id=\"cf-turnstile-cf7-3200884537\" class=\"cf-turnstile\" data-sitekey=\"0x4AAAAAABuDPzjTEgcGuVnP\" data-theme=\"auto\" data-language=\"auto\" data-size=\"normal\" data-retry=\"auto\" data-retry-interval=\"1000\" data-refresh-expired=\"auto\" data-action=\"contact-form-7\" data-appearance=\"always\"><\/div> <script>document.addEventListener(\"DOMContentLoaded\", function() { setTimeout(function(){ var e=document.getElementById(\"cf-turnstile-cf7-3200884537\"); e&&!e.innerHTML.trim()&&(turnstile.remove(\"#cf-turnstile-cf7-3200884537\"), turnstile.render(\"#cf-turnstile-cf7-3200884537\", {sitekey:\"0x4AAAAAABuDPzjTEgcGuVnP\"})); }, 100); });<\/script> <br class=\"cf-turnstile-br cf-turnstile-br-cf7-3200884537\"> <style>#cf-turnstile-cf7-3200884537 { margin-left: -15px; }<\/style> <script>document.addEventListener(\"DOMContentLoaded\",function(){document.querySelectorAll('.wpcf7-form').forEach(function(e){e.addEventListener('submit',function(){if(document.getElementById('cf-turnstile-cf7-3200884537')){setTimeout(function(){turnstile.reset('#cf-turnstile-cf7-3200884537');},1000)}})})});<\/script> <\/div><br\/><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n\t<\/p>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-5ac3509 e-flex e-con-boxed e-con e-parent\" data-id=\"5ac3509\" data-element_type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-2f96db2 elementor-widget elementor-widget-spacer\" data-id=\"2f96db2\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Regenerative Treatment Questionnaire For those interested in regenerative medicine, please fill out and submit the questionnaire before your consultation. By sharing your situation in advance, this will help shorten the consultation time and contribute to a more in-depth and productive session. \u203bDisclaimer: This form is used to collect information about patients and used for internal [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-9782","page","type-page","status-publish","hentry","no-thumb"],"_links":{"self":[{"href":"https:\/\/mrclinic.tokyo\/en\/wp-json\/wp\/v2\/pages\/9782","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/mrclinic.tokyo\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/mrclinic.tokyo\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/mrclinic.tokyo\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/mrclinic.tokyo\/en\/wp-json\/wp\/v2\/comments?post=9782"}],"version-history":[{"count":17,"href":"https:\/\/mrclinic.tokyo\/en\/wp-json\/wp\/v2\/pages\/9782\/revisions"}],"predecessor-version":[{"id":10525,"href":"https:\/\/mrclinic.tokyo\/en\/wp-json\/wp\/v2\/pages\/9782\/revisions\/10525"}],"wp:attachment":[{"href":"https:\/\/mrclinic.tokyo\/en\/wp-json\/wp\/v2\/media?parent=9782"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}