{"id":1171,"date":"2025-05-29T14:55:01","date_gmt":"2025-05-29T12:55:01","guid":{"rendered":"https:\/\/www.evomed.com.pl\/szczecin\/?page_id=1171"},"modified":"2025-05-29T15:11:33","modified_gmt":"2025-05-29T13:11:33","slug":"formularz","status":"publish","type":"page","link":"https:\/\/www.evomed.com.pl\/szczecin\/formularz\/","title":{"rendered":"Formularz"},"content":{"rendered":"\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-9d6595d7 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<h1 class=\"wp-block-heading\">Formularz kontaktowy<\/h1>\n\n\n\n<p>Kontakt z nami drog\u0105 elektroniczn\u0105, to najskuteczniejsza i najwygodniejsza forma kontaktu. Mo\u017cna zam\u00f3wi\u0107\u00a0<strong>e-recept\u0119<\/strong>\u00a0lub zam\u00f3wi\u0107\u00a0<strong>wyroby medyczne<\/strong> (np. pieluchomajtki, worki stomijne i inne).<\/p>\n\n\n\n                <div class=\"gf_browser_gecko gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital\" data-form-theme=\"orbital\" data-form-index=\"0\" id=\"gform_wrapper_1\" style=\"display:none\"><style>#gform_wrapper_1[data-form-index=\"0\"].gform-theme,[data-parent-form=\"1_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: #585e6a;--gf-color-out-ctrl-dark-rgb: 88, 94, 106;--gf-color-out-ctrl-dark-darker: #112337;--gf-color-out-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-color-in-ctrl: #fff;--gf-color-in-ctrl-rgb: 255, 255, 255;--gf-color-in-ctrl-contrast: #112337;--gf-color-in-ctrl-contrast-rgb: 17, 35, 55;--gf-color-in-ctrl-darker: #F5F5F5;--gf-color-in-ctrl-lighter: #FFFFFF;--gf-color-in-ctrl-primary: #204ce5;--gf-color-in-ctrl-primary-rgb: 32, 76, 229;--gf-color-in-ctrl-primary-contrast: #fff;--gf-color-in-ctrl-primary-contrast-rgb: 255, 255, 255;--gf-color-in-ctrl-primary-darker: #001AB3;--gf-color-in-ctrl-primary-lighter: #527EFF;--gf-color-in-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-in-ctrl-light-rgb: 17, 35, 55;--gf-color-in-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-in-ctrl-light-lighter: #F5F5F5;--gf-color-in-ctrl-dark: #585e6a;--gf-color-in-ctrl-dark-rgb: 88, 94, 106;--gf-color-in-ctrl-dark-darker: #112337;--gf-color-in-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-radius: 3px;--gf-font-size-secondary: 14px;--gf-font-size-tertiary: 13px;--gf-icon-ctrl-number: url(\"data:image\/svg+xml,%3Csvg width='8' height='14' viewBox='0 0 8 14' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-select: url(\"data:image\/svg+xml,%3Csvg width='10' height='6' viewBox='0 0 10 6' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg width='640' height='640' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><form method=\"post\" enctype=\"multipart\/form-data\" id=\"gform_1\" action=\"\/szczecin\/wp-json\/wp\/v2\/pages\/1171\" data-formid=\"1\" novalidate><input id=\"gpnf_session_hash_1\" type=\"hidden\" name=\"gpnf_session_hash\" value=\"eaed80164685\">\n                        <div class=\"gform-body gform_body\"><div id=\"gform_fields_1\" class=\"gform_fields top_label form_sublabel_below description_below validation_below\"><div id=\"field_1_1\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"><label class=\"gfield_label gform-field-label\" for=\"input_1_1\">Imi\u0119<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(wymagane)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_text\"><input name=\"input_1\" id=\"input_1_1\" type=\"text\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><\/div><\/div><div id=\"field_1_2\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"><label class=\"gfield_label gform-field-label\" for=\"input_1_2\">Nazwisko<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(wymagane)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_text\"><input name=\"input_2\" id=\"input_1_2\" type=\"text\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><\/div><\/div><div id=\"field_1_3\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"><label class=\"gfield_label gform-field-label\" for=\"input_1_3\">PESEL<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(wymagane)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_text\"><input name=\"input_3\" id=\"input_1_3\" type=\"text\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><\/div><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"><label class=\"gfield_label gform-field-label\" for=\"input_1_4\">Numer telefonu kontaktowego<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(wymagane)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_text\"><input name=\"input_4\" id=\"input_1_4\" type=\"text\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"><label class=\"gfield_label gform-field-label\" for=\"input_1_5\">Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(wymagane)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_email\">\n                            <input name=\"input_5\" id=\"input_1_5\" type=\"email\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\">\n                        <\/div><\/div><fieldset id=\"field_1_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"><legend class=\"gfield_label gform-field-label\">Wybierz temat<\/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=\"e-recepta\" checked 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\">e-recepta<\/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=\"wyroby medyczne\" 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\">wyroby medyczne<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_10\" class=\"gfield gfield--type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"><label class=\"gfield_label gform-field-label\" for=\"input_1_10\">e-recepta<\/label><div class=\"gpnf-nested-entries-container ginput_container\">\r\n\r\n\t<table class=\"gpnf-nested-entries\">\r\n\r\n\t\t<thead>\r\n\t\t<tr>\r\n\t\t\t\t\t\t\t<th class=\"gpnf-field-1\">\r\n\t\t\t\t\tNazwisko lekarza rodzinnego\t\t\t\t<\/th>\r\n\t\t\t\t\t\t\t<th class=\"gpnf-field-2\">\r\n\t\t\t\t\tNazwa leku\t\t\t\t<\/th>\r\n\t\t\t\t\t\t\t<th class=\"gpnf-field-3\">\r\n\t\t\t\t\tDawka leku\t\t\t\t<\/th>\r\n\t\t\t\t\t\t\t<th class=\"gpnf-field-4\">\r\n\t\t\t\t\tIlo\u015b\u0107 opakowa\u0144 leku\t\t\t\t<\/th>\r\n\t\t\t\t\t\t<th class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\r\n\t\t<\/tr>\r\n\t\t<\/thead>\r\n\r\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\r\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\r\n\t\t\t\t\t\t\t<td class=\"gpnf-field\" data-bind=\"html: f1.label, attr: { 'data-value': f1.label }\" data-heading=\"Nazwisko lekarza rodzinnego\">\u00a0<\/td>\r\n\t\t\t\t\t\t\t<td class=\"gpnf-field\" data-bind=\"html: f2.label, attr: { 'data-value': f2.label }\" data-heading=\"Nazwa leku\">\u00a0<\/td>\r\n\t\t\t\t\t\t\t<td class=\"gpnf-field\" data-bind=\"html: f3.label, attr: { 'data-value': f3.label }\" data-heading=\"Dawka leku\">\u00a0<\/td>\r\n\t\t\t\t\t\t\t<td class=\"gpnf-field\" data-bind=\"html: f4.label, attr: { 'data-value': f4.label }\" data-heading=\"Ilo\u015b\u0107 opakowa\u0144 leku\">\u00a0<\/td>\r\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\r\n\t\t\t\t<ul>\r\n\t\t\t\t\t<li class=\"edit\"><button class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Lek {0} where Nazwisko lekarza rodzinnego is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Edytuj<\/button><\/li>\r\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Lek {0} where Nazwisko lekarza rodzinnego is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Usu\u0144<\/button><\/li>\r\n\t\t\t\t<\/ul>\r\n\t\t\t<\/td>\r\n\t\t<\/tr>\r\n\t\t<\/tbody>\r\n\r\n\t\t<tbody data-bind=\"visible: entries().length &lt;= 0\">\r\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length &lt;= 0\" style=\"display: none;\">\r\n\t\t\t<td colspan=\"5\">\r\n\t\t\t\tNie dodano \u017cadnych <span>Lek\u00f3w.<\/span>\t\t\t<\/td>\r\n\t\t<\/tr>\r\n\t\t<\/tbody>\r\n\r\n\t<\/table>\r\n\r\n\t<button type=\"button\" class=\"gpnf-add-entry\" data-formid=\"1\" data-nestedformid=\"2\" data-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\">\r\n\t\t\t\tDodaj Lek\r\n\t\t\t<\/button>\t\r\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\r\n\t\t\t\tMaximum number of lek\u00f3w reached.\r\n\t\t\t<\/p>\r\n<\/div>\r\n<input type=\"hidden\" name=\"input_10\" id=\"input_1_10\" data-bind=\"value: entryIds\" value=\"\"><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"><label class=\"gfield_label gform-field-label\" for=\"input_1_11\">wyroby medyczne<\/label><div class=\"gpnf-nested-entries-container ginput_container\">\r\n\r\n\t<table class=\"gpnf-nested-entries\">\r\n\r\n\t\t<thead>\r\n\t\t<tr>\r\n\t\t\t\t\t\t\t<th class=\"gpnf-field-3\">\r\n\t\t\t\t\tNazwisko lekarza rodzinnego\t\t\t\t<\/th>\r\n\t\t\t\t\t\t\t<th class=\"gpnf-field-1\">\r\n\t\t\t\t\tProdukt\t\t\t\t<\/th>\r\n\t\t\t\t\t\t\t<th class=\"gpnf-field-2\">\r\n\t\t\t\t\tIlo\u015b\u0107\t\t\t\t<\/th>\r\n\t\t\t\t\t\t<th class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\r\n\t\t<\/tr>\r\n\t\t<\/thead>\r\n\r\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\r\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\r\n\t\t\t\t\t\t\t<td class=\"gpnf-field\" data-bind=\"html: f3.label, attr: { 'data-value': f3.label }\" data-heading=\"Nazwisko lekarza rodzinnego\">\u00a0<\/td>\r\n\t\t\t\t\t\t\t<td class=\"gpnf-field\" data-bind=\"html: f1.label, attr: { 'data-value': f1.label }\" data-heading=\"Produkt\">\u00a0<\/td>\r\n\t\t\t\t\t\t\t<td class=\"gpnf-field\" data-bind=\"html: f2.label, attr: { 'data-value': f2.label }\" data-heading=\"Ilo\u015b\u0107\">\u00a0<\/td>\r\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\r\n\t\t\t\t<ul>\r\n\t\t\t\t\t<li class=\"edit\"><button class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit wyr\u00f3b medyczny {0} where Nazwisko lekarza rodzinnego is {1}.'.gformFormat( $index() + 1, f3.label ) }\">Edytuj<\/button><\/li>\r\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete wyr\u00f3b medyczny {0} where Nazwisko lekarza rodzinnego is {1}.'.gformFormat( $index() + 1, f3.label ) }\">Usu\u0144<\/button><\/li>\r\n\t\t\t\t<\/ul>\r\n\t\t\t<\/td>\r\n\t\t<\/tr>\r\n\t\t<\/tbody>\r\n\r\n\t\t<tbody data-bind=\"visible: entries().length &lt;= 0\">\r\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length &lt;= 0\" style=\"display: none;\">\r\n\t\t\t<td colspan=\"4\">\r\n\t\t\t\tNie dodano \u017cadnych <span>wyrob\u00f3w medycznych.<\/span>\t\t\t<\/td>\r\n\t\t<\/tr>\r\n\t\t<\/tbody>\r\n\r\n\t<\/table>\r\n\r\n\t<button type=\"button\" class=\"gpnf-add-entry\" data-formid=\"1\" data-nestedformid=\"3\" data-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\">\r\n\t\t\t\tDodaj wyr\u00f3b medyczny\r\n\t\t\t<\/button>\t\r\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\r\n\t\t\t\tMaximum number of wyrob\u00f3w medycznych reached.\r\n\t\t\t<\/p>\r\n<\/div>\r\n<input type=\"hidden\" name=\"input_11\" id=\"input_1_11\" data-bind=\"value: entryIds\" value=\"\"><\/div><div id=\"field_1_12\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"><label class=\"gfield_label gform-field-label\" for=\"input_1_12\">Email<\/label><div class=\"ginput_container\"><input name=\"input_12\" id=\"input_1_12\" type=\"text\" value=\"\" autocomplete=\"new-password\"><\/div><div class=\"gfield_description\" id=\"gfield_description_1_12\">To pole jest u\u017cywane do walidacji i powinno pozosta\u0107 niezmienione.<\/div><\/div><\/div><\/div>\n        <div class=\"gform-footer gform_footer top_label\"> <input type=\"submit\" id=\"gform_submit_button_1\" class=\"gform_button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"submit\" value=\"Wy\u015blij\"> \n            <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_submission_method\" data-js=\"gform_submission_method_1\" value=\"postback\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_theme\" data-js=\"gform_theme_1\" id=\"gform_theme_1\" value=\"orbital\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_style_settings\" data-js=\"gform_style_settings_1\" id=\"gform_style_settings_1\" value='{\"inputPrimaryColor\":\"#204ce5\"}'>\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"is_submit_1\" value=\"1\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_submit\" value=\"1\">\n            \n            <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_unique_id\" value=\"\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"state_1\" value=\"WyJbXSIsImZkZDExYTZmNTRlZjFmZDJkMDljMmE0NGJiOGVmZmEzIl0=\">\n            <input type=\"hidden\" autocomplete=\"off\" class=\"gform_hidden\" name=\"gform_target_page_number_1\" id=\"gform_target_page_number_1\" value=\"0\">\n            <input type=\"hidden\" autocomplete=\"off\" class=\"gform_hidden\" name=\"gform_source_page_number_1\" id=\"gform_source_page_number_1\" value=\"1\">\n            <input type=\"hidden\" name=\"gform_field_values\" value=\"\">\n            \n        <\/div>\n                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