{"id":6752,"date":"2022-02-10T08:42:40","date_gmt":"2022-02-10T07:42:40","guid":{"rendered":"https:\/\/www.smilers.com\/eligible-formulaire\/"},"modified":"2024-04-18T16:49:31","modified_gmt":"2024-04-18T14:49:31","slug":"eligible-formulaire","status":"publish","type":"page","link":"https:\/\/www.smilers.com\/en\/eligible-formulaire\/","title":{"rendered":"eligible-formulaire"},"content":{"rendered":"<p>[vc_row][vc_column]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f5279-o1\" lang=\"en-US\" dir=\"ltr\">\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\/6752#wpcf7-f5279-o1\" method=\"post\" class=\"wpcf7-form init cf7mls-no-scroll cf7mls-no-moving-animation\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"5279\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.7.7\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f5279-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div class=\"fieldset-cf7mls-wrapper\" data-transition-effects><fieldset class=\"fieldset-cf7mls cf7mls_current_fs\"><div class=\"form-eligibility\">\n\t<h2>Front Smile\n\t<\/h2>\n\t<p><span class=\"eligibility-description\">Grit your teeth and capture your entire smile.<\/span>\n\t<\/p>\n\t<p><span class=\"eligibility-description\">Advice: Place your phone against something and put in on self-timer. For an optimum result, move your cheeks aside with your fingers.<\/span>\n\t<\/p>\n\t<div>\n\t\t<p><img decoding=\"async\" class=\"img_eligible\" src=\"https:\/\/www.smilers.com\/wp-content\/uploads\/2022\/02\/00420220208_095154-6.png\" \/>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"photo-upload-container\">\n\t\t<div class=\"photo-upload-div\">\n\t\t\t<div class=\"photo-upload-icon\">\n\t\t\t\t<p><span class=\"fa-stack fa-2x\"><i class=\"fas fa-circle fa-stack-2x\"><\/i><i class=\"fas fa-images fa-stack-1x fa-inverse\"><\/i><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"photo-upload-button\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap sourire_face wpcf7-images-optimize-upload-wrap\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-upload_image\" aria-invalid=\"false\" type=\"file\" data-name=\"sourire_face\" max-file-error=\"Maximum 1 image is allowed.\" max-file=\"1\" multiple=\"multiple\" accept=\"image\/png,image\/jpeg\"\/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"cf7mls-btns\"><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-1\">Next<img decoding=\"async\" src=\"https:\/\/www.smilers.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"\" data-lazy-src=\"https:\/\/www.smilers.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\" \/><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n<\/p>\n<div class=\"form-eligibility\">\n\t<h2>Left Smile\n\t<\/h2>\n\t<p><span class=\"eligibility-description\">Grit your teeth and capture your left profile.<\/span>\n\t<\/p>\n\t<p><span class=\"eligibility-description\">Advice: Move your cheek aside with one finger and use a mirror to adjust the picture.<\/span>\n\t<\/p>\n\t<div>\n\t\t<p><img decoding=\"async\" class=\"img_eligible\" src=\"https:\/\/www.smilers.com\/wp-content\/uploads\/2022\/02\/00520220208_095457-4.png\" \/>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"photo-upload-container\">\n\t\t<div class=\"photo-upload-div\">\n\t\t\t<div class=\"photo-upload-icon\">\n\t\t\t\t<p><span class=\"fa-stack fa-2x\"><i class=\"fas fa-circle fa-stack-2x\"><\/i><i class=\"fas fa-images fa-stack-1x fa-inverse\"><\/i><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"photo-upload-button\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap sourire_gauche wpcf7-images-optimize-upload-wrap\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-upload_image\" aria-invalid=\"false\" type=\"file\" data-name=\"sourire_gauche\" max-file-error=\"Maximum 1 image is allowed.\" max-file=\"1\" multiple=\"multiple\" accept=\"image\/png,image\/jpeg\"\/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"cf7mls-btns\"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-2\">Previous<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-2\">Next<img decoding=\"async\" src=\"https:\/\/www.smilers.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"\" data-lazy-src=\"https:\/\/www.smilers.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\" \/><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n<\/p>\n<div class=\"form-eligibility\">\n\t<h2>Grit your teeth and capture your right profile.\n\t<\/h2>\n\t<p><span class=\"eligibility-description\">Capture your smile in profile by keeping your teeth clenched.<\/span>\n\t<\/p>\n\t<p><span class=\"eligibility-description\">Advice: Move your cheek aside with one finger and use a mirror to adjust the picture.<\/span>\n\t<\/p>\n\t<div>\n\t\t<p><img decoding=\"async\" class=\"img_eligible\" src=\"https:\/\/www.smilers.com\/wp-content\/uploads\/2022\/02\/00620220208_095457_2-4.png\" \/>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"photo-upload-container\">\n\t\t<div class=\"photo-upload-div\">\n\t\t\t<div class=\"photo-upload-icon\">\n\t\t\t\t<p><span class=\"fa-stack fa-2x\"><i class=\"fas fa-circle fa-stack-2x\"><\/i><i class=\"fas fa-images fa-stack-1x fa-inverse\"><\/i><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"photo-upload-button\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap sourire_droite wpcf7-images-optimize-upload-wrap\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-upload_image\" aria-invalid=\"false\" type=\"file\" data-name=\"sourire_droite\" max-file-error=\"Maximum 1 image is allowed.\" max-file=\"1\" multiple=\"multiple\" accept=\"image\/png,image\/jpeg\"\/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"cf7mls-btns\"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-3\">Previous<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-3\">Next<img decoding=\"async\" src=\"https:\/\/www.smilers.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"\" data-lazy-src=\"https:\/\/www.smilers.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\" \/><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n<\/p>\n<div class=\"form-eligibility\">\n\t<h2>Upper dental arch\n\t<\/h2>\n\t<p><span class=\"eligibility-description\">Capture your upper teeth.<\/span>\n\t<\/p>\n\t<p><span class=\"eligibility-description\">Advice: Open your mouth and use a mirror to adjust the picture.<\/span>\n\t<\/p>\n\t<div>\n\t\t<p><img decoding=\"async\" class=\"img_eligible\" src=\"https:\/\/www.smilers.com\/wp-content\/uploads\/2022\/02\/01020220209_100830-5.png\" \/>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"photo-upload-container\">\n\t\t<div class=\"photo-upload-div\">\n\t\t\t<div class=\"photo-upload-icon\">\n\t\t\t\t<p><span class=\"fa-stack fa-2x\"><i class=\"fas fa-circle fa-stack-2x\"><\/i><i class=\"fas fa-images fa-stack-1x fa-inverse\"><\/i><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"photo-upload-button\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap arcade_haut wpcf7-images-optimize-upload-wrap\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-upload_image\" aria-invalid=\"false\" type=\"file\" data-name=\"arcade_haut\" max-file-error=\"Maximum 1 image is allowed.\" max-file=\"1\" multiple=\"multiple\" accept=\"image\/png,image\/jpeg\"\/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"cf7mls-btns\"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-4\">Previous<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-4\">Next<img decoding=\"async\" src=\"https:\/\/www.smilers.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"\" data-lazy-src=\"https:\/\/www.smilers.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\" \/><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n<\/p>\n<div class=\"form-eligibility\">\n\t<h2>Lower dental arch\n\t<\/h2>\n\t<p><span class=\"eligibility-description\">Capture your lower teeth.<\/span>\n\t<\/p>\n\t<p><span class=\"eligibility-description\">Avice: Open your mouth and use a mirror to adjust the picture.<\/span>\n\t<\/p>\n\t<div>\n\t\t<p><img decoding=\"async\" class=\"img_eligible\" src=\"https:\/\/www.smilers.com\/wp-content\/uploads\/2022\/02\/00920220208_095647-4.png\" \/>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"photo-upload-container\">\n\t\t<div class=\"photo-upload-div\">\n\t\t\t<div class=\"photo-upload-icon\">\n\t\t\t\t<p><span class=\"fa-stack fa-2x\"><i class=\"fas fa-circle fa-stack-2x\"><\/i><i class=\"fas fa-images fa-stack-1x fa-inverse\"><\/i><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"photo-upload-button\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap arcade_bas wpcf7-images-optimize-upload-wrap\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-upload_image\" aria-invalid=\"false\" type=\"file\" data-name=\"arcade_bas\" max-file-error=\"Maximum 1 image is allowed.\" max-file=\"1\" multiple=\"multiple\" accept=\"image\/png,image\/jpeg\"\/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"cf7mls-btns\"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-5\">Previous<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-5\">Next<img decoding=\"async\" src=\"https:\/\/www.smilers.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"\" data-lazy-src=\"https:\/\/www.smilers.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\" \/><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n<\/p>\n<div class=\"form-halfcol\">\n\t<div class=\"halfcol\">\n\t\t<p><label><br \/>\nMy practitioner recommended that I remove my wisdom teeth.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sagesse\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"sagesse\" value=\"Yes\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"sagesse\" value=\"No\" \/><\/span><\/span><\/span><br \/>\n<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"halfcol\">\n\t\t<p><label><br \/>\nI have dental implants and bridges.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"implant\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"implant\" value=\"Yes\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"implant\" value=\"No\" \/><\/span><\/span><\/span><br \/>\n<\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"form-halfcol\">\n\t<div class=\"halfcol\">\n\t\t<p><label><br \/>\nI have a contention wire on my teeth.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"fil\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"fil\" value=\"Yes\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"fil\" value=\"No\" \/><\/span><\/span><\/span><br \/>\n<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"halfcol\">\n\t\t<p><label><br \/>\nI have gum issues.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"gencives\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"gencives\" value=\"Yes\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"gencives\" value=\"No\" \/><\/span><\/span><\/span><br \/>\n<\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"form-halfcol\">\n\t<div class=\"halfcol\">\n\t\t<p><label><br \/>\nI have seen a dentist in the past 6 months.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dentiste\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"dentiste\" value=\"Yes\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"dentiste\" value=\"No\" \/><\/span><\/span><\/span><br \/>\n<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"halfcol\">\n\t\t<p><label><br \/>\nI already had an orthodontics treatment.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ortho\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"ortho\" value=\"Yes\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"ortho\" value=\"No\" \/><\/span><\/span><\/span><br \/>\n<\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"form-halfcol\">\n\t<div class=\"halfcol\">\n\t\t<p><label><br \/>\nI am feeling pain in the jaw or difficulties to open, close or chew.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"douleur\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"checkbox\" name=\"douleur\" value=\"Yes\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"checkbox\" name=\"douleur\" value=\"No\" \/><\/span><\/span><\/span><br \/>\n<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"halfcol\">\n\t\t<p><label><br \/>\nI would like to correct<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"correction\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">My alignment<\/span><input type=\"checkbox\" name=\"correction[]\" value=\"My alignment\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">My Occlusion<\/span><input type=\"checkbox\" name=\"correction[]\" value=\"My Occlusion\" \/><\/span><\/span><\/span><br \/>\n<\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"form-halfcol\">\n\t<div class=\"halfcol\">\n\t\t<p><label><br \/>\nComment<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"comment\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"comment\" \/><\/span><br \/>\n<\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"cf7mls-btns\"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-6\">Previous<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-6\">Next<img decoding=\"async\" src=\"https:\/\/www.smilers.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"\" data-lazy-src=\"https:\/\/www.smilers.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\" \/><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n<\/p>\n<div class=\"form-halfcol\">\n\t<div class=\"halfcol\">\n\t\t<p><label> Lastname<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"halfcol\">\n\t\t<p><label> Firstname<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-firstname\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-firstname\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"form-halfcol\">\n\t<div class=\"halfcol\">\n\t\t<p><label> Birth date<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"date-733\"><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=\"date-733\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"halfcol\">\n\t\t<p><label> Adress<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"address\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"form-halfcol\">\n\t<div class=\"halfcol\">\n\t\t<p><label> Zip Code<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"zipCode\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"zipCode\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"halfcol\">\n\t\t<p><label> City<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"city\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"city\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"form-halfcol\">\n\t<div class=\"halfcol\">\n\t\t<p><label> Country<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Country\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Country\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"halfcol\">\n\t\t<p><label> Phone number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tel-666\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"tel-666\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"form-halfcol\">\n\t<div class=\"halfcol\">\n\t\t<p><label> E-mail<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" 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