{"id":1233,"date":"2026-03-14T22:47:56","date_gmt":"2026-03-14T15:47:56","guid":{"rendered":"https:\/\/bhm.chantrastudio.com\/?page_id=1233"},"modified":"2026-04-30T10:01:52","modified_gmt":"2026-04-30T10:01:52","slug":"new-patient-registration","status":"publish","type":"page","link":"https:\/\/bhm.chantrastudio.com\/en\/patient-services\/outpatient\/new-patient-registration\/","title":{"rendered":"New Patient Registration"},"content":{"rendered":"\n<div class=\"wp-block-group has-background is-layout-constrained wp-block-group-is-layout-constrained\" style=\"background-color:#fafafa;padding-top:var(--wp--preset--spacing--24);padding-bottom:var(--wp--preset--spacing--32)\"><div class=\"breadcrumbs align wp-block-bcn-breadcrumb-trail has-text-color has-background\" vocab=\"https:\/\/schema.org\/\" typeof=\"BreadcrumbList\">\n\t<span><\/span>\n\t<span property=\"itemListElement\" typeof=\"ListItem\">\r\n<a property=\"item\" typeof=\"WebPage\" title=\"Go to \u0e2b\u0e19\u0e49\u0e32\u0e41\u0e23\u0e01\" href=\"https:\/\/bhm.chantrastudio.com\/en\/\" class=\"home\">\r\n<span property=\"name\">\u0e2b\u0e19\u0e49\u0e32\u0e41\u0e23\u0e01<\/span>\r\n<\/a>\r\n<meta property=\"position\" content=\"1\">\r\n<\/span><\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-cover\" style=\"min-height:300px;aspect-ratio:unset;\"><img loading=\"lazy\" decoding=\"async\" width=\"1440\" height=\"810\" class=\"wp-block-cover__image-background wp-image-476 size-full\" alt=\"\" src=\"https:\/\/bhm.chantrastudio.com\/wp-content\/uploads\/2026\/03\/40c7c245f1413620d9a01fd669ac67cd8406e42d.webp\" data-object-fit=\"cover\" srcset=\"https:\/\/bhm.chantrastudio.com\/wp-content\/uploads\/2026\/03\/40c7c245f1413620d9a01fd669ac67cd8406e42d.webp 1440w, https:\/\/bhm.chantrastudio.com\/wp-content\/uploads\/2026\/03\/40c7c245f1413620d9a01fd669ac67cd8406e42d-300x169.webp 300w, https:\/\/bhm.chantrastudio.com\/wp-content\/uploads\/2026\/03\/40c7c245f1413620d9a01fd669ac67cd8406e42d-1024x576.webp 1024w, https:\/\/bhm.chantrastudio.com\/wp-content\/uploads\/2026\/03\/40c7c245f1413620d9a01fd669ac67cd8406e42d-768x432.webp 768w\" sizes=\"auto, (max-width: 1440px) 100vw, 1440px\" \/><span aria-hidden=\"true\" class=\"wp-block-cover__background has-background-dim-90 has-background-dim wp-block-cover__gradient-background has-background-gradient\" style=\"background:linear-gradient(135deg,rgb(51,104,198) 0%,rgba(166,198,255,0.83) 100%)\"><\/span><div class=\"wp-block-cover__inner-container is-layout-constrained wp-block-cover-is-layout-constrained\">\n<div class=\"wp-block-group is-layout-constrained wp-container-core-group-is-layout-7fc5ad6d wp-block-group-is-layout-constrained\" style=\"border-left-width:2px;padding-top:var(--wp--preset--spacing--8);padding-bottom:var(--wp--preset--spacing--8);padding-left:var(--wp--preset--spacing--36)\"><h2 style=\"font-style:normal;font-weight:600\" class=\"wp-block-post-title has-5-xl-font-size\">New Patient Registration<\/h2>\n\n\n<p class=\"wp-block-paragraph\">\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e2a\u0e33\u0e2b\u0e23\u0e31\u0e1a\u0e14\u0e32\u0e27\u0e19\u0e4c\u0e42\u0e2b\u0e25\u0e14 \u0e42\u0e23\u0e07\u0e1e\u0e22\u0e32\u0e1a\u0e32\u0e25\u0e20\u0e39\u0e21\u0e34\u0e1e\u0e25\u0e2f<\/p>\n<\/div>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-group has-background is-layout-constrained wp-block-group-is-layout-constrained\" style=\"background-color:#f8f8f8\">\n<div class=\"wp-block-group is-layout-constrained wp-block-group-is-layout-constrained\" style=\"padding-top:var(--wp--preset--spacing--32);padding-bottom:var(--wp--preset--spacing--64)\"><div class=\"frm_forms  with_frm_style frm_style_register-style\" id=\"frm_form_2_container\" data-token=\"8bdce693c7f70190af4c216558ee4c8f\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_jatvu\" data-token=\"8bdce693c7f70190af4c216558ee4c8f\">\n<div class=\"frm_form_fields  frm_page_num_1\">\n<fieldset>\n<legend class=\"frm_screen_reader\">\u0e25\u0e07\u0e17\u0e30\u0e40\u0e1a\u0e35\u0e22\u0e19\u0e1c\u0e39\u0e49\u0e1b\u0e48\u0e27\u0e22\u0e43\u0e2b\u0e21\u0e48<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<div class=\"frm_rootline_group\" role=\"group\" tabindex=\"0\" aria-label=\"Page 1 of 3\" ><ul class=\"frm_page_bar frm_rootline_3 frm_rootline frm_rootline_line  frm_show_lines \"><li class=\"frm_rootline_single frm_current_page\"><input type=\"button\" value=\"1\" data-page=\"\" class=\" frm_page_1\" aria-disabled=\"true\" data-field=\"0\" aria-label=\"Page 1\"  \/><\/li><li class=\"frm_rootline_single\"><input type=\"button\" value=\"2\" data-page=\"33\" class=\"frm_page_skip frm_page_2\" data-field=\"19\" aria-label=\"Next\"  \/><\/li><li class=\"frm_rootline_single\"><input type=\"button\" value=\"3\" data-page=\"83\" class=\"frm_page_skip frm_page_3\" data-field=\"84\" aria-label=\"Page 3\"  \/><\/li><\/ul><div class=\"frm_clearfix\"><\/div><\/div><input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"2\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_2\" id=\"frm_hide_fields_2\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"jatvu\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_2\" name=\"frm_submit_entry_2\" value=\"3b136fda72\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/1233\" \/><div id=\"frm_field_49_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_first\">\n<h3 class=\"frm_pos_top frm_section_spacing\">\u0e02\u0e49\u0e2d\u0e21\u0e39\u0e25\u0e1b\u0e23\u0e30\u0e08\u0e33\u0e15\u0e31\u0e27\u0e1c\u0e39\u0e49\u0e1b\u0e48\u0e27\u0e22<\/h3>\n\n\n<div id=\"frm_field_33_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\n\t<label for=\"field_patient_id\" id=\"field_patient_id_label\" class=\"frm_primary_label\">\u0e40\u0e25\u0e02\u0e17\u0e35\u0e48\u0e1a\u0e31\u0e15\u0e23\u0e1b\u0e23\u0e30\u0e0a\u0e32\u0e0a\u0e19\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_patient_id\" name=\"item_meta[33]\" value=\"\"  data-sectionid=\"49\"  data-frmmask=\"0-0000-00000-00-0\" placeholder=\"\u0e01\u0e23\u0e2d\u0e01\u0e40\u0e25\u0e02\u0e1a\u0e31\u0e15\u0e23\u0e1b\u0e23\u0e30\u0e0a\u0e32\u0e0a\u0e19\" data-reqmsg=\"\u0e40\u0e25\u0e02\u0e17\u0e35\u0e48\u0e1a\u0e31\u0e15\u0e23\u0e1b\u0e23\u0e30\u0e0a\u0e32\u0e0a\u0e19 cannot be blank.\" aria-required=\"true\" data-invmsg=\"\u0e40\u0e25\u0e02\u0e17\u0e35\u0e48\u0e1a\u0e31\u0e15\u0e23\u0e1b\u0e23\u0e30\u0e0a\u0e32\u0e0a\u0e19 is invalid\" aria-invalid=\"false\" pattern=\"\\d-\\d\\d\\d\\d-\\d\\d\\d\\d\\d-\\d\\d-\\d$\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_31_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio vertical_radio frm_other_container\">\n\t<div  id=\"field_6vt0o_label\" class=\"frm_primary_label\">\u0e04\u0e33\u0e19\u0e33\u0e2b\u0e19\u0e49\u0e32\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/div>\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_6vt0o_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_31-49-0\">\t\t\t<label  for=\"field_6vt0o-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[31]\" id=\"field_6vt0o-0\" value=\"\u0e19\u0e32\u0e22\"\n\t\t data-sectionid=\"49\"  data-reqmsg=\"\u0e04\u0e33\u0e19\u0e33\u0e2b\u0e19\u0e49\u0e32 cannot be blank.\" data-invmsg=\"\u0e04\u0e33\u0e19\u0e33\u0e2b\u0e19\u0e49\u0e32 is invalid\"   \/> \u0e19\u0e32\u0e22<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_31-49-1\">\t\t\t<label  for=\"field_6vt0o-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[31]\" id=\"field_6vt0o-1\" value=\"\u0e19\u0e32\u0e07\"\n\t\t data-sectionid=\"49\"  data-reqmsg=\"\u0e04\u0e33\u0e19\u0e33\u0e2b\u0e19\u0e49\u0e32 cannot be blank.\" data-invmsg=\"\u0e04\u0e33\u0e19\u0e33\u0e2b\u0e19\u0e49\u0e32 is invalid\"   \/> \u0e19\u0e32\u0e07<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_31-49-2\">\t\t\t<label  for=\"field_6vt0o-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[31]\" id=\"field_6vt0o-2\" value=\"\u0e19\u0e32\u0e07\u0e2a\u0e32\u0e27\"\n\t\t data-sectionid=\"49\"  data-reqmsg=\"\u0e04\u0e33\u0e19\u0e33\u0e2b\u0e19\u0e49\u0e32 cannot be blank.\" data-invmsg=\"\u0e04\u0e33\u0e19\u0e33\u0e2b\u0e19\u0e49\u0e32 is invalid\"   \/> \u0e19\u0e32\u0e07\u0e2a\u0e32\u0e27<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_31-49-3\">\t\t\t<label  for=\"field_6vt0o-3\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[31]\" id=\"field_6vt0o-3\" value=\"\u0e14.\u0e0a.\"\n\t\t data-sectionid=\"49\"  data-reqmsg=\"\u0e04\u0e33\u0e19\u0e33\u0e2b\u0e19\u0e49\u0e32 cannot be blank.\" data-invmsg=\"\u0e04\u0e33\u0e19\u0e33\u0e2b\u0e19\u0e49\u0e32 is invalid\"   \/> \u0e14.\u0e0a.<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_31-49-4\">\t\t\t<label  for=\"field_6vt0o-4\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[31]\" id=\"field_6vt0o-4\" value=\"\u0e14.\u0e0d.\"\n\t\t data-sectionid=\"49\"  data-reqmsg=\"\u0e04\u0e33\u0e19\u0e33\u0e2b\u0e19\u0e49\u0e32 cannot be blank.\" data-invmsg=\"\u0e04\u0e33\u0e19\u0e33\u0e2b\u0e19\u0e49\u0e32 is invalid\"   \/> \u0e14.\u0e0d.<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_31-49-6\">\t\t\t<label  for=\"field_6vt0o-6\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[31]\" id=\"field_6vt0o-6\" value=\"\u0e22\u0e28\"\n\t\t data-sectionid=\"49\"  data-reqmsg=\"\u0e04\u0e33\u0e19\u0e33\u0e2b\u0e19\u0e49\u0e32 cannot be blank.\" data-invmsg=\"\u0e04\u0e33\u0e19\u0e33\u0e2b\u0e19\u0e49\u0e32 is invalid\"   \/> \u0e22\u0e28<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_31-49-other_5\">\t\t\t<label  for=\"field_6vt0o-other_5\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[31]\" id=\"field_6vt0o-other_5\" value=\"\u0e2d\u0e37\u0e48\u0e19\u0e46\"\n\t\t data-sectionid=\"49\"  data-reqmsg=\"\u0e04\u0e33\u0e19\u0e33\u0e2b\u0e19\u0e49\u0e32 cannot be blank.\" data-invmsg=\"\u0e04\u0e33\u0e19\u0e33\u0e2b\u0e19\u0e49\u0e32 is invalid\"   \/> \u0e2d\u0e37\u0e48\u0e19\u0e46<\/label><label for=\"field_6vt0o-other_5-otext\" class=\"frm_screen_reader frm_hidden\">\u0e2d\u0e37\u0e48\u0e19\u0e46<\/label><input type=\"text\" id=\"field_6vt0o-other_5-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][31]\" value=\"\" \/><\/div>\n<\/div>\n\t\n\t\n<\/div>\n<div id=\"frm_field_92_container\" class=\"frm_form_field form-field  frm_hidden_container frm_half\">\n\t<label for=\"field_p2mva\" id=\"field_p2mva_label\" class=\"frm_primary_label\">\u0e22\u0e28\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t\t\t<select name=\"item_meta[92]\" id=\"field_p2mva\"  data-sectionid=\"49\"  data-placeholder=\"\u0e42\u0e1b\u0e23\u0e14\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e22\u0e28\"  placeholder=\"\u0e42\u0e1b\u0e23\u0e14\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e22\u0e28\" data-invmsg=\"\u0e22\u0e28 is invalid\" aria-invalid=\"false\"  >\n\t\t<option  class=\"frm-select-placeholder\" value=\"\" data-placeholder=\"true\">\u0e42\u0e1b\u0e23\u0e14\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e22\u0e28<\/option><option  value=\"\u0e1e\u0e25\u0e40\u0e23\u0e37\u0e2d\u0e40\u0e2d\u0e01\">\u0e1e\u0e25\u0e40\u0e23\u0e37\u0e2d\u0e40\u0e2d\u0e01<\/option><option  value=\"\u0e1e\u0e25\u0e40\u0e23\u0e37\u0e2d\u0e42\u0e17\">\u0e1e\u0e25\u0e40\u0e23\u0e37\u0e2d\u0e42\u0e17<\/option><option  value=\"\u0e1e\u0e25\u0e40\u0e23\u0e37\u0e2d\u0e15\u0e23\u0e35\">\u0e1e\u0e25\u0e40\u0e23\u0e37\u0e2d\u0e15\u0e23\u0e35<\/option><option  value=\"\u0e19\u0e32\u0e27\u0e32\u0e40\u0e2d\u0e01\">\u0e19\u0e32\u0e27\u0e32\u0e40\u0e2d\u0e01<\/option><option  value=\"\u0e19\u0e32\u0e27\u0e32\u0e42\u0e17\">\u0e19\u0e32\u0e27\u0e32\u0e42\u0e17<\/option><option  value=\"\u0e19\u0e32\u0e27\u0e32\u0e15\u0e23\u0e35\">\u0e19\u0e32\u0e27\u0e32\u0e15\u0e23\u0e35<\/option><option  value=\"\u0e40\u0e23\u0e37\u0e2d\u0e40\u0e2d\u0e01\">\u0e40\u0e23\u0e37\u0e2d\u0e40\u0e2d\u0e01<\/option><option  value=\"\u0e40\u0e23\u0e37\u0e2d\u0e42\u0e17\">\u0e40\u0e23\u0e37\u0e2d\u0e42\u0e17<\/option><option  value=\"\u0e40\u0e23\u0e37\u0e2d\u0e40\u0e2d\u0e01\u0e15\u0e23\u0e35\">\u0e40\u0e23\u0e37\u0e2d\u0e40\u0e2d\u0e01\u0e15\u0e23\u0e35<\/option><option  value=\"\u0e1e\u0e31\u0e19\u0e08\u0e48\u0e32\u0e40\u0e2d\u0e01\">\u0e1e\u0e31\u0e19\u0e08\u0e48\u0e32\u0e40\u0e2d\u0e01<\/option><option  value=\"\u0e1e\u0e31\u0e19\u0e08\u0e48\u0e32\u0e42\u0e17\">\u0e1e\u0e31\u0e19\u0e08\u0e48\u0e32\u0e42\u0e17<\/option><option  value=\"\u0e1e\u0e31\u0e19\u0e08\u0e48\u0e32\u0e15\u0e23\u0e35\">\u0e1e\u0e31\u0e19\u0e08\u0e48\u0e32\u0e15\u0e23\u0e35<\/option><option  value=\"\u0e08\u0e48\u0e32\u0e40\u0e2d\u0e01\">\u0e08\u0e48\u0e32\u0e40\u0e2d\u0e01<\/option><option  value=\"\u0e08\u0e48\u0e32\u0e42\u0e17\">\u0e08\u0e48\u0e32\u0e42\u0e17<\/option><option  value=\"\u0e08\u0e48\u0e32\u0e15\u0e23\u0e35\">\u0e08\u0e48\u0e32\u0e15\u0e23\u0e35<\/option><option  value=\"\u0e1e\u0e25\u0e17\u0e2b\u0e32\u0e23\u0e40\u0e23\u0e37\u0e2d\">\u0e1e\u0e25\u0e17\u0e2b\u0e32\u0e23\u0e40\u0e23\u0e37\u0e2d<\/option>\t<\/select>\n\t\n\t\n\t\n<\/div>\n<div id=\"frm_field_93_container\" class=\"frm_form_field form-field  frm_top_container frm_half frm_other_container\">\n\t<label for=\"field_ajahv\" id=\"field_ajahv_label\" class=\"frm_primary_label\">\u0e2a\u0e31\u0e07\u0e01\u0e31\u0e14\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t\t\t<select name=\"item_meta[93]\" id=\"field_ajahv\"  data-sectionid=\"49\"  data-invmsg=\"\u0e2a\u0e31\u0e07\u0e01\u0e31\u0e14 is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\u0e02\u0e49\u0e32\u0e23\u0e32\u0e0a\u0e01\u0e32\u0e23 \u0e17\u0e2d.\">\u0e02\u0e49\u0e32\u0e23\u0e32\u0e0a\u0e01\u0e32\u0e23 \u0e17\u0e2d.<\/option><option  value=\"\u0e1a\u0e33\u0e19\u0e32\u0e0d \u0e17\u0e2d.\">\u0e1a\u0e33\u0e19\u0e32\u0e0d \u0e17\u0e2d.<\/option><option  value=\"\u0e04\u0e23\u0e2d\u0e1a\u0e04\u0e23\u0e31\u0e27 \u0e17\u0e2d.\">\u0e04\u0e23\u0e2d\u0e1a\u0e04\u0e23\u0e31\u0e27 \u0e17\u0e2d.<\/option><option  value=\"\u0e02\u0e49\u0e32\u0e23\u0e32\u0e0a\u0e01\u0e32\u0e23 \u0e17\u0e1a, \u0e17\u0e23, \u0e15\u0e23\">\u0e02\u0e49\u0e32\u0e23\u0e32\u0e0a\u0e01\u0e32\u0e23 \u0e17\u0e1a, \u0e17\u0e23, \u0e15\u0e23<\/option><option  value=\"\u0e02\u0e49\u0e32\u0e23\u0e32\u0e0a\u0e32\u0e23\u0e1e\u0e25\u0e40\u0e23\u0e37\u0e2d\u0e19\">\u0e02\u0e49\u0e32\u0e23\u0e32\u0e0a\u0e32\u0e23\u0e1e\u0e25\u0e40\u0e23\u0e37\u0e2d\u0e19<\/option><option  value=\"\u0e1e\u0e25\u0e40\u0e23\u0e37\u0e2d\u0e19\">\u0e1e\u0e25\u0e40\u0e23\u0e37\u0e2d\u0e19<\/option><option  value=\"\u0e2d\u0e37\u0e48\u0e19\u0e46 \u0e23\u0e30\u0e1a\u0e38\" class=\"frm_other_trigger\">\u0e2d\u0e37\u0e48\u0e19\u0e46 \u0e23\u0e30\u0e1a\u0e38<\/option>\t<\/select>\n\t<label for=\"field_ajahv-otext\" class=\"frm_screen_reader frm_hidden\">\u0e2a\u0e31\u0e07\u0e01\u0e31\u0e14<\/label><input type=\"text\" id=\"field_ajahv-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][93]\" value=\"\" \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_8_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n\t<label for=\"field_patient_name\" id=\"field_patient_name_label\" class=\"frm_primary_label\">\u0e0a\u0e37\u0e48\u0e2d\u0e08\u0e23\u0e34\u0e07\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_patient_name\" name=\"item_meta[8]\" value=\"\"  data-sectionid=\"49\"  placeholder=\"\u0e01\u0e23\u0e2d\u0e01\u0e0a\u0e37\u0e48\u0e2d\u0e08\u0e23\u0e34\u0e07\" data-reqmsg=\"\u0e0a\u0e37\u0e48\u0e2d\u0e08\u0e23\u0e34\u0e07 cannot be blank.\" aria-required=\"true\" data-invmsg=\"\u0e0a\u0e37\u0e48\u0e2d\u0e08\u0e23\u0e34\u0e07 is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_34_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n\t<label for=\"field_patient_surname\" id=\"field_patient_surname_label\" class=\"frm_primary_label\">\u0e19\u0e32\u0e21\u0e2a\u0e01\u0e38\u0e25\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_patient_surname\" name=\"item_meta[34]\" value=\"\"  data-sectionid=\"49\"  placeholder=\"\u0e01\u0e23\u0e2d\u0e01\u0e19\u0e32\u0e21\u0e2a\u0e01\u0e38\u0e25\" data-reqmsg=\"\u0e19\u0e32\u0e21\u0e2a\u0e01\u0e38\u0e25 cannot be blank.\" aria-required=\"true\" data-invmsg=\"\u0e19\u0e32\u0e21\u0e2a\u0e01\u0e38\u0e25 is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_37_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n\t<label for=\"field_o4liv\" id=\"field_o4liv_label\" class=\"frm_primary_label\">First Name\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_o4liv\" name=\"item_meta[37]\" value=\"\"  data-sectionid=\"49\"  placeholder=\"\u0e01\u0e23\u0e2d\u0e01\u0e0a\u0e37\u0e48\u0e2d\u0e08\u0e23\u0e34\u0e07\u0e20\u0e32\u0e29\u0e32\u0e2d\u0e31\u0e07\u0e01\u0e24\u0e29\" data-reqmsg=\"First Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"First Name is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_36_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n\t<label for=\"field_ogalq\" id=\"field_ogalq_label\" class=\"frm_primary_label\">Lastname\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_ogalq\" name=\"item_meta[36]\" value=\"\"  data-sectionid=\"49\"  placeholder=\"\u0e01\u0e23\u0e2d\u0e01\u0e19\u0e32\u0e21\u0e2a\u0e01\u0e38\u0e25\u0e20\u0e32\u0e29\u0e32\u0e2d\u0e31\u0e07\u0e01\u0e24\u0e29\" data-reqmsg=\"Lastname cannot be blank.\" aria-required=\"true\" data-invmsg=\"Lastname is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_38_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio frm6 frm_first vertical_radio\">\n\t<div  id=\"field_7yb6q_label\" class=\"frm_primary_label\">\u0e40\u0e1e\u0e28\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/div>\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_7yb6q_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_38-49-0\">\t\t\t<label  for=\"field_7yb6q-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[38]\" id=\"field_7yb6q-0\" value=\"\u0e0a\u0e32\u0e22\"\n\t\t data-sectionid=\"49\"  data-reqmsg=\"\u0e40\u0e1e\u0e28 cannot be blank.\" data-invmsg=\"\u0e40\u0e1e\u0e28 is invalid\"   \/> \u0e0a\u0e32\u0e22<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_38-49-1\">\t\t\t<label  for=\"field_7yb6q-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[38]\" id=\"field_7yb6q-1\" value=\"\u0e2b\u0e0d\u0e34\u0e07\"\n\t\t data-sectionid=\"49\"  data-reqmsg=\"\u0e40\u0e1e\u0e28 cannot be blank.\" data-invmsg=\"\u0e40\u0e1e\u0e28 is invalid\"   \/> \u0e2b\u0e0d\u0e34\u0e07<\/label><\/div>\n<\/div>\n\t\n\t\n<\/div>\n<div id=\"frm_field_39_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\n\t<label for=\"field_tcxjd\" id=\"field_tcxjd_label\" class=\"frm_primary_label\">\u0e40\u0e0a\u0e37\u0e49\u0e2d\u0e0a\u0e32\u0e15\u0e34\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_tcxjd\" name=\"item_meta[39]\" value=\"\"  data-sectionid=\"49\"  placeholder=\"\u0e01\u0e23\u0e2d\u0e01\u0e02\u0e49\u0e2d\u0e21\u0e39\u0e25\" data-reqmsg=\"\u0e40\u0e0a\u0e37\u0e49\u0e2d\u0e0a\u0e32\u0e15\u0e34 cannot be blank.\" aria-required=\"true\" data-invmsg=\"\u0e40\u0e0a\u0e37\u0e49\u0e2d\u0e0a\u0e32\u0e15\u0e34 is invalid\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_40_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\n\t<label for=\"field_daoj4\" id=\"field_daoj4_label\" class=\"frm_primary_label\">\u0e2a\u0e31\u0e0d\u0e0a\u0e32\u0e15\u0e34\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_daoj4\" name=\"item_meta[40]\" value=\"\"  data-sectionid=\"49\"  placeholder=\"\u0e01\u0e23\u0e2d\u0e01\u0e02\u0e49\u0e2d\u0e21\u0e39\u0e25\" data-reqmsg=\"\u0e2a\u0e31\u0e0d\u0e0a\u0e32\u0e15\u0e34 cannot be blank.\" aria-required=\"true\" data-invmsg=\"\u0e2a\u0e31\u0e0d\u0e0a\u0e32\u0e15\u0e34 is invalid\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_41_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\n\t<label for=\"field_c4zlx\" id=\"field_c4zlx_label\" class=\"frm_primary_label\">\u0e28\u0e32\u0e2a\u0e19\u0e32\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_c4zlx\" name=\"item_meta[41]\" value=\"\"  data-sectionid=\"49\"  placeholder=\"\u0e01\u0e23\u0e2d\u0e01\u0e02\u0e49\u0e2d\u0e21\u0e39\u0e25\" data-reqmsg=\"\u0e28\u0e32\u0e2a\u0e19\u0e32 cannot be blank.\" aria-required=\"true\" data-invmsg=\"\u0e28\u0e32\u0e2a\u0e19\u0e32 is invalid\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_42_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first\">\n\t<label for=\"field_lo92l\" id=\"field_lo92l_label\" class=\"frm_primary_label\">\u0e2a\u0e16\u0e32\u0e19\u0e20\u0e32\u0e1e\u0e2a\u0e21\u0e23\u0e2a\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t\t\t<select name=\"item_meta[42]\" id=\"field_lo92l\"  data-sectionid=\"49\"  data-placeholder=\"\u0e42\u0e1b\u0e23\u0e14\u0e40\u0e25\u0e37\u0e2d\u0e01\"  placeholder=\"\u0e42\u0e1b\u0e23\u0e14\u0e40\u0e25\u0e37\u0e2d\u0e01\" data-reqmsg=\"\u0e2a\u0e16\u0e32\u0e19\u0e20\u0e32\u0e1e\u0e2a\u0e21\u0e23\u0e2a cannot be blank.\" aria-required=\"true\" data-invmsg=\"\u0e2a\u0e16\u0e32\u0e19\u0e20\u0e32\u0e1e\u0e2a\u0e21\u0e23\u0e2a is invalid\" aria-invalid=\"false\"  >\n\t\t<option  class=\"frm-select-placeholder\" value=\"\" data-placeholder=\"true\">\u0e42\u0e1b\u0e23\u0e14\u0e40\u0e25\u0e37\u0e2d\u0e01<\/option><option  value=\"\u0e42\u0e2a\u0e14\">\u0e42\u0e2a\u0e14<\/option><option  value=\"\u0e2a\u0e21\u0e23\u0e2a\">\u0e2a\u0e21\u0e23\u0e2a<\/option><option  value=\"\u0e2b\u0e22\u0e48\u0e32\">\u0e2b\u0e22\u0e48\u0e32<\/option><option  value=\"\u0e2b\u0e21\u0e49\u0e32\u0e22\">\u0e2b\u0e21\u0e49\u0e32\u0e22<\/option>\t<\/select>\n\t\n\t\n\t\n<\/div>\n<div id=\"frm_field_43_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4\">\n\t<label for=\"field_57nbf\" id=\"field_57nbf_label\" class=\"frm_primary_label\">\u0e2d\u0e32\u0e0a\u0e35\u0e1e\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_57nbf\" name=\"item_meta[43]\" value=\"\"  data-sectionid=\"49\"  placeholder=\"\u0e01\u0e23\u0e2d\u0e01\u0e02\u0e49\u0e2d\u0e21\u0e39\u0e25\" data-reqmsg=\"\u0e2d\u0e32\u0e0a\u0e35\u0e1e cannot be blank.\" aria-required=\"true\" data-invmsg=\"\u0e2d\u0e32\u0e0a\u0e35\u0e1e is invalid\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_44_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4\">\n\t<label for=\"field_sqk6k\" id=\"field_sqk6k_label\" class=\"frm_primary_label\">\u0e2b\u0e21\u0e39\u0e48\u0e40\u0e25\u0e37\u0e2d\u0e14\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t\t\t<select name=\"item_meta[44]\" id=\"field_sqk6k\"  data-sectionid=\"49\"  data-placeholder=\"\u0e42\u0e1b\u0e23\u0e14\u0e40\u0e25\u0e37\u0e2d\u0e01\"  placeholder=\"\u0e42\u0e1b\u0e23\u0e14\u0e40\u0e25\u0e37\u0e2d\u0e01\" data-reqmsg=\"\u0e2b\u0e21\u0e39\u0e48\u0e40\u0e25\u0e37\u0e2d\u0e14 cannot be blank.\" aria-required=\"true\" data-invmsg=\"\u0e2b\u0e21\u0e39\u0e48\u0e40\u0e25\u0e37\u0e2d\u0e14 is invalid\" aria-invalid=\"false\"  >\n\t\t<option  class=\"frm-select-placeholder\" value=\"\" data-placeholder=\"true\">\u0e42\u0e1b\u0e23\u0e14\u0e40\u0e25\u0e37\u0e2d\u0e01<\/option><option  value=\"A\">A<\/option><option  value=\"B\">B<\/option><option  value=\"AB\">AB<\/option><option  value=\"O\">O<\/option><option  value=\"\u0e44\u0e21\u0e48\u0e17\u0e23\u0e32\u0e1a\">\u0e44\u0e21\u0e48\u0e17\u0e23\u0e32\u0e1a<\/option>\t<\/select>\n\t\n\t\n\t\n<\/div>\n<div id=\"frm_field_45_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm_first\">\n\t<label for=\"field_17uf\" id=\"field_17uf_label\" class=\"frm_primary_label\">\u0e0a\u0e37\u0e48\u0e2d-\u0e2a\u0e01\u0e38\u0e25 \u0e1a\u0e34\u0e14\u0e32\u0e1c\u0e39\u0e49\u0e1b\u0e48\u0e27\u0e22\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_17uf\" name=\"item_meta[45]\" value=\"\"  data-sectionid=\"49\"  placeholder=\"\u0e01\u0e23\u0e2d\u0e01\u0e0a\u0e37\u0e48\u0e2d\u0e08\u0e23\u0e34\u0e07 \u0e19\u0e32\u0e21\u0e2a\u0e01\u0e38\u0e25\u0e1a\u0e34\u0e14\u0e32\u0e1c\u0e39\u0e49\u0e1b\u0e48\u0e27\u0e22\" data-invmsg=\"\u0e0a\u0e37\u0e48\u0e2d-\u0e2a\u0e01\u0e38\u0e25 \u0e1a\u0e34\u0e14\u0e32\u0e1c\u0e39\u0e49\u0e1b\u0e48\u0e27\u0e22 is invalid\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_46_container\" class=\"frm_form_field form-field  frm_top_container frm6\">\n\t<label for=\"field_u14q7\" id=\"field_u14q7_label\" class=\"frm_primary_label\">\u0e0a\u0e37\u0e48\u0e2d-\u0e2a\u0e01\u0e38\u0e25  \u0e21\u0e32\u0e23\u0e14\u0e32\u0e1c\u0e39\u0e49\u0e1b\u0e48\u0e27\u0e22\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_u14q7\" name=\"item_meta[46]\" value=\"\"  data-sectionid=\"49\"  placeholder=\"\u0e01\u0e23\u0e2d\u0e01\u0e0a\u0e37\u0e48\u0e2d\u0e08\u0e23\u0e34\u0e07 \u0e19\u0e32\u0e21\u0e2a\u0e01\u0e38\u0e25\u0e21\u0e32\u0e23\u0e14\u0e32\u0e1c\u0e39\u0e49\u0e1b\u0e48\u0e27\u0e22\" data-invmsg=\"\u0e0a\u0e37\u0e48\u0e2d-\u0e2a\u0e01\u0e38\u0e25  \u0e21\u0e32\u0e23\u0e14\u0e32\u0e1c\u0e39\u0e49\u0e1b\u0e48\u0e27\u0e22 is invalid\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_47_container\" class=\"frm_form_field form-field  frm_inline_container horizontal_radio frm_first frm_third vertical_radio\">\n\t<div  id=\"field_aplzk_label\" class=\"frm_primary_label\">\u0e0a\u0e37\u0e48\u0e2d-\u0e2a\u0e01\u0e38\u0e25\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/div>\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_aplzk_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_47-49-0\">\t\t\t<label  for=\"field_aplzk-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[47]\" id=\"field_aplzk-0\" value=\"\u0e2a\u0e32\u0e21\u0e35\u0e1c\u0e39\u0e49\u0e1b\u0e48\u0e27\u0e22\"\n\t\t data-sectionid=\"49\"  data-invmsg=\"\u0e0a\u0e37\u0e48\u0e2d-\u0e2a\u0e01\u0e38\u0e25 is invalid\"   \/> \u0e2a\u0e32\u0e21\u0e35\u0e1c\u0e39\u0e49\u0e1b\u0e48\u0e27\u0e22<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_47-49-1\">\t\t\t<label  for=\"field_aplzk-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[47]\" id=\"field_aplzk-1\" value=\"\u0e20\u0e23\u0e23\u0e22\u0e32\u0e1c\u0e39\u0e49\u0e1b\u0e48\u0e27\u0e22\"\n\t\t data-sectionid=\"49\"  data-invmsg=\"\u0e0a\u0e37\u0e48\u0e2d-\u0e2a\u0e01\u0e38\u0e25 is invalid\"   \/> \u0e20\u0e23\u0e23\u0e22\u0e32\u0e1c\u0e39\u0e49\u0e1b\u0e48\u0e27\u0e22<\/label><\/div>\n<\/div>\n\t\n\t\n<\/div>\n<div id=\"frm_field_48_container\" class=\"frm_form_field form-field  frm_none_container frm_two_thirds\">\n\t<label for=\"field_36ag\" id=\"field_36ag_label\" class=\"frm_primary_label\">\u0e0a\u0e37\u0e48\u0e2d\u0e2a\u0e01\u0e38\u0e25\u0e20\u0e23\u0e23\u0e22\u0e32\u0e2b\u0e23\u0e37\u0e2d\u0e2a\u0e32\u0e21\u0e35\u0e1c\u0e39\u0e49\u0e1b\u0e48\u0e27\u0e22\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_36ag\" name=\"item_meta[48]\" value=\"\"  data-sectionid=\"49\"  placeholder=\"\u0e01\u0e23\u0e2d\u0e01\u0e02\u0e49\u0e2d\u0e21\u0e39\u0e25\" data-invmsg=\"\u0e0a\u0e37\u0e48\u0e2d\u0e2a\u0e01\u0e38\u0e25\u0e20\u0e23\u0e23\u0e22\u0e32\u0e2b\u0e23\u0e37\u0e2d\u0e2a\u0e32\u0e21\u0e35\u0e1c\u0e39\u0e49\u0e1b\u0e48\u0e27\u0e22 is invalid\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<\/div>\n<input type=\"hidden\" name=\"frm_page_order_2\" id=\"frm_page_order_2\" value=\"33\" \/>\t\t<input  type=\"hidden\" name=\"item_meta[51]\" id=\"field_bohz3\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[20]\" id=\"field_zipcode\" value=\"\"  data-sectionid=\"51\"     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data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[59]\" id=\"field_j66dv\" value=\"\"  data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[61]\" id=\"field_address_now-0\" value=\"\"  data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[62]\" id=\"field_zipcode_house_registration\" value=\"\"  data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[65]\" id=\"field_k73w6\" value=\"\"  data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[66]\" id=\"field_ud5wo\" value=\"\"  data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[64]\" id=\"field_yu09i\" value=\"\"  data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[70]\" id=\"field_butqp\" value=\"\"  data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[69]\" id=\"field_district_house_registration\" value=\"\"  data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[68]\" id=\"field_amphoe_house_registration\" value=\"\"  data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[67]\" id=\"field_province_house_registration\" value=\"\"  data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[72]\" id=\"field_zipcode_contacted\" value=\"\"  data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[74]\" id=\"field_ywdpu\" value=\"\"  data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[75]\" id=\"field_2nn6t\" value=\"\"  data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[73]\" id=\"field_zrq5o\" value=\"\"  data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[78]\" id=\"field_ibwkq\" value=\"\"  data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[79]\" id=\"field_district_contacted\" value=\"\"  data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[76]\" id=\"field_amphoe_contacted\" value=\"\"  data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[77]\" id=\"field_province_contacted\" value=\"\"  data-sectionid=\"51\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[52]\" id=\"field_hli8n\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[84]\" id=\"field_whw7a\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[80]\" id=\"field_37bb1\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[82]\" id=\"field_qb9d8-0\" value=\"\u0e41\u0e1e\u0e49(\u0e23\u0e30\u0e1a\u0e38)\"  data-sectionid=\"80\"  data-frmval=\"\u0e41\u0e1e\u0e49(\u0e23\u0e30\u0e1a\u0e38)\"   \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[83]\" id=\"field_r076t\" value=\"\"  data-sectionid=\"80\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[81]\" id=\"field_8253x\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[6]\" id=\"field_submit\" value=\"\"     \/>\n\t\t\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_94_container\">\n\t\t\t<label for=\"field_8x1go\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_8x1go\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[94]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"3Yw98aWlCF+kb4L\/rWcuj0JnXo5osgA16r8CM5l3CctxtlZLWEgwMDUhKSIa\/Hc2\" \/><div class=\"frm_submit frm_flex\">\r\n<button class=\"frm_button_submit\" type=\"submit\"  >\u0e16\u0e31\u0e14\u0e44\u0e1b &gt;&gt;<\/button>\r\n\r\n\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n\n<\/div>\n<\/div>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":1238,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"advgb_blocks_editor_width":"","advgb_blocks_columns_visual_guide":"","footnotes":""},"class_list":["post-1233","page","type-page","status-publish","hentry"],"acf":[],"coauthors":[],"author_meta":{"author_link":"https:\/\/bhm.chantrastudio.com\/en\/author\/wasinee\/","display_name":"wasinee"},"relative_dates":{"created":"Posted 2 months ago","modified":"Updated 3 weeks ago"},"absolute_dates":{"created":"Posted on 14 March 2026","modified":"Updated on 30 April 2026"},"absolute_dates_time":{"created":"Posted on 14 March 2026 10:47 pm","modified":"Updated on 30 April 2026 10:01 am"},"featured_img_caption":"","featured_img":false,"series_order":"","_links":{"self":[{"href":"https:\/\/bhm.chantrastudio.com\/en\/wp-json\/wp\/v2\/pages\/1233","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/bhm.chantrastudio.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/bhm.chantrastudio.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/bhm.chantrastudio.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/bhm.chantrastudio.com\/en\/wp-json\/wp\/v2\/comments?post=1233"}],"version-history":[{"count":0,"href":"https:\/\/bhm.chantrastudio.com\/en\/wp-json\/wp\/v2\/pages\/1233\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/bhm.chantrastudio.com\/en\/wp-json\/wp\/v2\/pages\/1238"}],"wp:attachment":[{"href":"https:\/\/bhm.chantrastudio.com\/en\/wp-json\/wp\/v2\/media?parent=1233"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}