{"id":4949,"date":"2021-03-13T18:03:22","date_gmt":"2021-03-13T14:33:22","guid":{"rendered":"http:\/\/persian-health.com\/?page_id=4949"},"modified":"2021-03-13T18:17:32","modified_gmt":"2021-03-13T14:47:32","slug":"congenital-anomalies-form","status":"publish","type":"page","link":"https:\/\/medical1.persian-health.com\/en\/congenital-anomalies-form\/","title":{"rendered":"Congenital anomalies form"},"content":{"rendered":"\n\t<div id=\"gap-1030783927\" class=\"gap-element clearfix\" style=\"display:block; height:auto;\">\n\t\t\n<style>\n#gap-1030783927 {\n  padding-top: 30px;\n}\n<\/style>\n\t<\/div>\n\t\n\n<div class=\"container section-title-container\" ><h3 class=\"section-title section-title-center\"><b><\/b><span class=\"section-title-main\" style=\"color:rgb(61, 0, 87);\">Congenital anomalies surgeries application form<\/span><b><\/b><\/h3><\/div>\n\n<div class=\"row align-equal align-right\"  id=\"row-1846330235\">\n\n\n\t<div id=\"col-1712015554\" class=\"col medium-2 small-12 large-2\"  >\n\t\t<div class=\"col-inner\"  >\n\t\t\t\n\t\t\t\n\n\n\t\t<\/div>\n\t\t\t<\/div>\n\n\t\n\n\t<div id=\"col-1655541720\" class=\"col medium-8 small-12 large-8\"  >\n\t\t<div class=\"col-inner text-left\"  >\n\t\t\t\n\t\t\t\n\n<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f4936-o1\" lang=\"fa-IR\" dir=\"rtl\">\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\/4949#wpcf7-f4936-o1\" method=\"post\" class=\"wpcf7-form init\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"4936\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.4\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fa_IR\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f4936-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<p><label> Child\u2019s first name<br \/>\n<span class=\"wpcf7-form-control-wrap Childsfirstname\"><input type=\"text\" name=\"Childsfirstname\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/label><\/p>\n<p><label> Child\u2019s last name<br \/>\n<span class=\"wpcf7-form-control-wrap Childslastname\"><input type=\"text\" name=\"Childslastname\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> Father\/Mother first name<br \/>\n<span class=\"wpcf7-form-control-wrap FatherMotherfirstname\"><input type=\"text\" name=\"FatherMotherfirstname\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><label><\/p>\n<p><label> Date of birth<br \/>\n   <span class=\"wpcf7-form-control-wrap Dateofbirth\"><input type=\"date\" name=\"Dateofbirth\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> Sex<br \/>\n     <span class=\"wpcf7-form-control-wrap radio-35\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-35\" value=\"rather not say\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">rather not say<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-35\" value=\"female\" \/><span class=\"wpcf7-list-item-label\">female<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-35\" value=\"male\" \/><span class=\"wpcf7-list-item-label\">male<\/span><\/label><\/span><\/span><\/span><\/label><\/p>\n<p><label> country<br \/>\n    <span class=\"wpcf7-form-control-wrap country\"><input type=\"text\" name=\"country\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label><\/p>\n<p><label> City<br \/>\n    <span class=\"wpcf7-form-control-wrap City\"><input type=\"text\" name=\"City\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label><\/p>\n<p><label> Address<br \/>\n    <span class=\"wpcf7-form-control-wrap Address\"><textarea name=\"Address\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span> <\/label><\/p>\n<p><label> Parent\u2019s mobile phone number<br \/>\n   <span class=\"wpcf7-form-control-wrap Parentsmobilephonenumber\"><input type=\"tel\" name=\"Parentsmobilephonenumber\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> Phone Number<br \/>\n    <span class=\"wpcf7-form-control-wrap Phone\"><input type=\"tel\" name=\"Phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"+983130000000\" \/><\/span><\/label><\/p>\n<p><label> Email<br \/>\n<span class=\"wpcf7-form-control-wrap email-153\"><input type=\"email\" name=\"email-153\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label><\/p>\n<p><label> :Describe the anomaly you need intervention for<br \/>\n    <span class=\"wpcf7-form-control-wrap Description\"><textarea name=\"Description\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span> <\/label><\/p>\n<p><label> Family history (Congenital anomalies in first- or second-grade family members)<br \/>\n   <span class=\"wpcf7-form-control-wrap Familyhistory\"><textarea name=\"Familyhistory\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span> <\/label><\/p>\n<p><label> Previous doctors\u2019 comments (if available)<br \/>\n<span class=\"wpcf7-form-control-wrap Previousdoctorscomments\"><textarea name=\"Previousdoctorscomments\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span><label><\/p>\n<p><label> Please attach at least one and a maximum of three pictures of the anomalies<br \/>\n<span class=\"wpcf7-form-control-wrap file-631\"><input type=\"file\" name=\"file-631\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.jpeg,.png,.gif,.pdf,.doc,.docx,.ppt,.pptx,.odt,.avi,.ogg,.m4a,.mov,.mp3,.mp4,.mpg,.wav,.wmv\" aria-invalid=\"false\" \/><\/span><span class=\"wpcf7-form-control-wrap file-916\"><input type=\"file\" name=\"file-916\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.jpeg,.png,.gif,.pdf,.doc,.docx,.ppt,.pptx,.odt,.avi,.ogg,.m4a,.mov,.mp3,.mp4,.mpg,.wav,.wmv\" aria-invalid=\"false\" \/><\/span><span class=\"wpcf7-form-control-wrap file-915\"><input type=\"file\" name=\"file-915\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.jpeg,.png,.gif,.pdf,.doc,.docx,.ppt,.pptx,.odt,.avi,.ogg,.m4a,.mov,.mp3,.mp4,.mpg,.wav,.wmv\" aria-invalid=\"false\" \/><\/span> <\/label><\/p>\n<p><label> Please attach a video and show the anomalies in the video<br \/>\n<span class=\"wpcf7-form-control-wrap file-696\"><input type=\"file\" name=\"file-696\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.jpeg,.png,.gif,.pdf,.doc,.docx,.ppt,.pptx,.odt,.avi,.ogg,.m4a,.mov,.mp3,.mp4,.mpg,.wav,.wmv\" aria-invalid=\"false\" \/><\/span><label><\/p>\n<p><label>?Which method do you prefer for communication<br \/>\n<span class=\"wpcf7-form-control-wrap radio-505\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-505\" value=\"WhatsApp\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">WhatsApp<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-505\" value=\"Email\" \/><span class=\"wpcf7-list-item-label\">Email<\/span><\/label><\/span><\/span><\/span><\/label><\/p>\n<p><label> What language do you prefer for communication?<br \/>\n<span class=\"wpcf7-form-control-wrap radio-565\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-565\" value=\"English\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">English<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-565\" value=\"French\" \/><span class=\"wpcf7-list-item-label\">French<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-565\" value=\"Arabic\" \/><span class=\"wpcf7-list-item-label\">Arabic<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-565\" value=\"Turkish\" \/><span class=\"wpcf7-list-item-label\">Turkish<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-565\" value=\"Farsi\" \/><span class=\"wpcf7-list-item-label\">Farsi<\/span><\/label><\/span><\/span><\/span><label><\/p>\n<p><input type=\"submit\" value=\"Submit\" class=\"wpcf7-form-control wpcf7-submit\" \/><\/p>\n<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div>\n\n\n\t\t<\/div>\n\t\t\t<\/div>\n\n\t\n\n\t<div id=\"col-728922564\" class=\"col medium-2 small-12 large-2\"  >\n\t\t<div class=\"col-inner\"  >\n\t\t\t\n\t\t\t\n\n\n\t\t<\/div>\n\t\t\t<\/div>\n\n\t\n\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-blank.php","meta":{"footnotes":""},"class_list":["post-4949","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v16.1.1 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Congenital anomalies form - persian health<\/title>\n<link rel=\"canonical\" href=\"https:\/\/medical1.persian-health.com\/en\/congenital-anomalies-form\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Congenital anomalies form - persian health\" \/>\n<meta property=\"og:url\" content=\"https:\/\/medical1.persian-health.com\/en\/congenital-anomalies-form\/\" \/>\n<meta property=\"og:site_name\" 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