{"id":1034,"date":"2026-05-20T01:57:07","date_gmt":"2026-05-20T01:57:07","guid":{"rendered":"https:\/\/dymmedicalclinic.id\/en\/?page_id=1034"},"modified":"2026-05-20T01:59:33","modified_gmt":"2026-05-20T01:59:33","slug":"booking","status":"publish","type":"page","link":"https:\/\/dymmedicalclinic.id\/en\/mcu\/booking\/","title":{"rendered":"booking"},"content":{"rendered":"\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1031-o1\" lang=\"ja\" 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\/1034#wpcf7-f1031-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"1031\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9.8\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"ja\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1031-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div class=\"formpart\">\n\t<div class=\"formname\">\n\t\t<div class=\"name\">\n\t\t\t<p>Gender\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"require\">\n\t\t\t<p>Required\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"forminput\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"sex\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"sex\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"sex\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"sex\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"formpart\">\n\t<div class=\"formname\">\n\t\t<div class=\"name\">\n\t\t\t<p>Name (in Roman letters)\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"require\">\n\t\t\t<p>Required\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"forminput hopeday_box\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"familyname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"YAMADA\" value=\"\" type=\"text\" name=\"familyname\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"firstname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"TARO\" value=\"\" type=\"text\" name=\"firstname\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"formpart\">\n\t<div class=\"formname\">\n\t\t<div class=\"name\">\n\t\t\t<p>Date of birth\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"require\">\n\t\t\t<p>Required\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"forminput birthday_box\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"birth_year\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"birth_year\"><option value=\"Year\">Year<\/option><option value=\"1930\">1930<\/option><option value=\"1931\">1931<\/option><option value=\"1932\">1932<\/option><option value=\"1933\">1933<\/option><option value=\"1934\">1934<\/option><option value=\"1935\">1935<\/option><option value=\"1936\">1936<\/option><option value=\"1937\">1937<\/option><option value=\"1938\">1938<\/option><option value=\"1939\">1939<\/option><option value=\"1940\">1940<\/option><option value=\"1941\">1941<\/option><option value=\"1942\">1942<\/option><option value=\"1943\">1943<\/option><option value=\"1944\">1944<\/option><option value=\"1945\">1945<\/option><option value=\"1946\">1946<\/option><option value=\"1947\">1947<\/option><option value=\"1948\">1948<\/option><option value=\"1949\">1949<\/option><option value=\"1950\">1950<\/option><option value=\"1951\">1951<\/option><option value=\"1952\">1952<\/option><option value=\"1953\">1953<\/option><option value=\"1954\">1954<\/option><option value=\"1955\">1955<\/option><option value=\"1956\">1956<\/option><option value=\"1957\">1957<\/option><option value=\"1958\">1958<\/option><option value=\"1959\">1959<\/option><option value=\"1960\">1960<\/option><option value=\"1961\">1961<\/option><option value=\"1962\">1962<\/option><option value=\"1963\">1963<\/option><option value=\"1964\">1964<\/option><option value=\"1965\">1965<\/option><option value=\"1966\">1966<\/option><option value=\"1967\">1967<\/option><option value=\"1968\">1968<\/option><option value=\"1969\">1969<\/option><option value=\"1970\">1970<\/option><option value=\"1971\">1971<\/option><option value=\"1972\">1972<\/option><option value=\"1973\">1973<\/option><option value=\"1974\">1974<\/option><option value=\"1975\">1975<\/option><option value=\"1976\">1976<\/option><option value=\"1977\">1977<\/option><option value=\"1978\">1978<\/option><option value=\"1979\">1979<\/option><option value=\"1980\">1980<\/option><option value=\"1981\">1981<\/option><option value=\"1982\">1982<\/option><option value=\"1983\">1983<\/option><option value=\"1984\">1984<\/option><option value=\"1985\">1985<\/option><option value=\"1986\">1986<\/option><option value=\"1987\">1987<\/option><option value=\"1988\">1988<\/option><option value=\"1989\">1989<\/option><option value=\"1990\">1990<\/option><option value=\"1991\">1991<\/option><option value=\"1992\">1992<\/option><option value=\"1993\">1993<\/option><option value=\"1994\">1994<\/option><option value=\"1995\">1995<\/option><option value=\"1996\">1996<\/option><option value=\"1997\">1997<\/option><option value=\"1998\">1998<\/option><option value=\"1999\">1999<\/option><option value=\"2000\">2000<\/option><option value=\"2001\">2001<\/option><option value=\"2002\">2002<\/option><option value=\"2003\">2003<\/option><option value=\"2004\">2004<\/option><option value=\"2005\">2005<\/option><option value=\"2006\">2006<\/option><option value=\"2007\">2007<\/option><option value=\"2008\">2008<\/option><option value=\"2009\">2009<\/option><option value=\"2010\">2010<\/option><option value=\"2011\">2011<\/option><option value=\"2012\">2012<\/option><option value=\"2013\">2013<\/option><option value=\"2014\">2014<\/option><option value=\"2015\">2015<\/option><option value=\"2016\">2016<\/option><option value=\"2017\">2017<\/option><option value=\"2018\">2018<\/option><option value=\"2019\">2019<\/option><option value=\"2020\">2020<\/option><option value=\"2021\">2021<\/option><option value=\"2022\">2022<\/option><option value=\"2023\">2023<\/option><\/select><\/span><br \/>\n\/ <span class=\"wpcf7-form-control-wrap\" data-name=\"birth_month\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"birth_month\"><option value=\"Month\">Month<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><\/select><\/span><br \/>\n\/ <span class=\"wpcf7-form-control-wrap\" data-name=\"birth_day\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"birth_day\"><option value=\"Day\">Day<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><option value=\"13\">13<\/option><option value=\"14\">14<\/option><option value=\"15\">15<\/option><option value=\"16\">16<\/option><option value=\"17\">17<\/option><option value=\"18\">18<\/option><option value=\"19\">19<\/option><option value=\"20\">20<\/option><option value=\"21\">21<\/option><option value=\"22\">22<\/option><option value=\"23\">23<\/option><option value=\"24\">24<\/option><option value=\"25\">25<\/option><option value=\"26\">26<\/option><option value=\"27\">27<\/option><option value=\"28\">28<\/option><option value=\"29\">29<\/option><option value=\"30\">30<\/option><option value=\"31\">31<\/option><\/select><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"formpart\">\n\t<div class=\"formname\">\n\t\t<div class=\"name\">\n\t\t\t<p>Mobile phone number\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"require\">\n\t\t\t<p>Required\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"forminput\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"tel\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"021-1111-2222\" value=\"\" type=\"text\" name=\"tel\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"formpart\">\n\t<div class=\"formname\">\n\t\t<div class=\"name\">\n\t\t\t<p>Email address\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"require\">\n\t\t\t<p>Required\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"forminput\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"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\" placeholder=\"124@aaa.co.id\" value=\"\" type=\"email\" name=\"email\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"formpart\">\n\t<div class=\"formname\">\n\t\t<div class=\"name\">\n\t\t\t<p>Email address (confirmation)\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"require\">\n\t\t\t<p>Required\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"forminput\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"email_confirm\"><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\" placeholder=\"124@aaa.co.id\" value=\"\" type=\"email\" name=\"email_confirm\" \/><\/span>\n\t\t<\/p>\n\t\t<div class=\"error-message\" id=\"email-error\">\n\t\t\t<p>The email addresses do not match.\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"formpart\">\n\t<div class=\"formname\">\n\t\t<div class=\"name\">\n\t\t\t<p>Preferred appointment date and time\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"require\">\n\t\t\t<p>Required\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"forminput hopeday_box\">\n\t\t<div>\n\t\t\t<p>First preference\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"kibou1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required hopeday\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"select date\" value=\"\" type=\"text\" name=\"kibou1\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"kibou1-2\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"kibou1-2\"><option value=\"Select a time\">Select a time<\/option><option value=\"8:00\uff5e\">8:00\uff5e<\/option><option value=\"8:30\uff5e\">8:30\uff5e<\/option><option value=\"9:00\uff5e\">9:00\uff5e<\/option><option value=\"9:30\uff5e\">9:30\uff5e<\/option><option value=\"10:00\uff5e\">10:00\uff5e<\/option><option value=\"10:30\uff5e\">10:30\uff5e<\/option><option value=\"13:00\uff5e\">13:00\uff5e<\/option><\/select><\/span>\n\t\t<\/p>\n\t\t<div>\n\t\t\t<p>Second preference\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"kibou2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required hopeday\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"select date\" value=\"\" type=\"text\" name=\"kibou2\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"kibou2-2\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"kibou2-2\"><option value=\"Select a time\">Select a time<\/option><option value=\"8:00\uff5e\">8:00\uff5e<\/option><option value=\"8:30\uff5e\">8:30\uff5e<\/option><option value=\"9:00\uff5e\">9:00\uff5e<\/option><option value=\"9:30\uff5e\">9:30\uff5e<\/option><option value=\"10:00\uff5e\">10:00\uff5e<\/option><option value=\"10:30\uff5e\">10:30\uff5e<\/option><option value=\"13:00\uff5e\">13:00\uff5e<\/option><\/select><\/span>\n\t\t<\/p>\n\t\t<p><br \/>\nPlease be advised that urine tests, stool samples, and gynecological examinations cannot be accurately conducted during your menstrual period. If your health package includes these specific tests, you will be asked to return to the clinic at a later date.\n\t\t<\/p>\n\t\t<p>We recommend that you undergo the checkup from the 4th day onward, counting the day after menstruation ends as Day 1.\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"formpart\">\n\t<div class=\"formname\">\n\t\t<div class=\"name\">\n\t\t\t<p>Plan\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"require\">\n\t\t\t<p>Required\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"forminput brelement\">\n\t\t<div class=\"plan\" style=\"margin-bottom: 20px;\">\n\t\t\t<p>Please check the plan details <a href=\"https:\/\/dymmedicalclinic.id\/wp-content\/uploads\/2025\/05\/DYM\u30d1\u30c3\u30b1\u30fc\u30b8_2025.pdf\" target=\"_blank\" style=\"color: #007bff; text-decoration: underline; font-weight: bold;\">here<\/a>.\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"plan\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"plan\" value=\"Essential Package (Rp750,000)\" \/><span class=\"wpcf7-list-item-label\">Essential Package (Rp750,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"plan\" value=\"Basic Package (Rp1,150,000)\" \/><span class=\"wpcf7-list-item-label\">Basic Package (Rp1,150,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"plan\" value=\"Standard Package (Rp1,800,000)\" \/><span class=\"wpcf7-list-item-label\">Standard Package (Rp1,800,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"plan\" value=\"Comprehensive Package (Rp2,700,000)\" \/><span class=\"wpcf7-list-item-label\">Comprehensive Package (Rp2,700,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"plan\" value=\"Premium Package (Rp3,500,000)\" \/><span class=\"wpcf7-list-item-label\">Premium Package (Rp3,500,000)<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"formpart\">\n\t<div class=\"formname\">\n\t\t<div class=\"name\">\n\t\t\t<p>Optional tests\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"require nini\">\n\t\t\t<p>Optional\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"forminput brelement option_dropdown_wrap\">\n\t\t<div class=\"option_dropdown\">\n\t\t\t<p><button type=\"button\" class=\"category-mini option_toggle\">-Ophthalmology tests<\/button>\n\t\t\t<\/p>\n\t\t\t<div class=\"option_menu\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"option\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Tonometry (Rp150,000)\" \/><span class=\"wpcf7-list-item-label\">Tonometry (Rp150,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Fundus examination (Rp350,000)\" \/><span class=\"wpcf7-list-item-label\">Fundus examination (Rp350,000)<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"option_dropdown\">\n\t\t\t<p><button type=\"button\" class=\"category-mini option_toggle\">-Other<\/button>\n\t\t\t<\/p>\n\t\t\t<div class=\"option_menu\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"option\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Pulmonary function test (Spirometry) (Rp250,000)\" \/><span class=\"wpcf7-list-item-label\">Pulmonary function test (Spirometry) (Rp250,000)<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"category\">\n\t\t\t<p>Blood tests\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"option_dropdown\">\n\t\t\t<p><button type=\"button\" class=\"category-mini option_toggle\">-Anemia<\/button>\n\t\t\t<\/p>\n\t\t\t<div class=\"option_menu\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"option\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Serum iron (Rp325,000)\" \/><span class=\"wpcf7-list-item-label\">Serum iron (Rp325,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Ferritin (Rp564,000)\" \/><span class=\"wpcf7-list-item-label\">Ferritin (Rp564,000)<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"option_dropdown\">\n\t\t\t<p><button type=\"button\" class=\"category-mini option_toggle\">-Rheumatism<\/button>\n\t\t\t<\/p>\n\t\t\t<div class=\"option_menu\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"option\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Rheumatoid factor (qualitative) (Rp172,000)\" \/><span class=\"wpcf7-list-item-label\">Rheumatoid factor (qualitative) (Rp172,000)<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"option_dropdown\">\n\t\t\t<p><button type=\"button\" class=\"category-mini option_toggle\">-Pancreatic function<\/button>\n\t\t\t<\/p>\n\t\t\t<div class=\"option_menu\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"option\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Amylase (Rp270,000)\" \/><span class=\"wpcf7-list-item-label\">Amylase (Rp270,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Lactate dehydrogenase (LDH) (Rp293,000)\" \/><span class=\"wpcf7-list-item-label\">Lactate dehydrogenase (LDH) (Rp293,000)<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"option_dropdown\">\n\t\t\t<p><button type=\"button\" class=\"category-mini option_toggle\">-Glucose metabolism<\/button>\n\t\t\t<\/p>\n\t\t\t<div class=\"option_menu\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"option\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"option[]\" value=\"HbA1c (Rp228,000)\" \/><span class=\"wpcf7-list-item-label\">HbA1c (Rp228,000)<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"option_dropdown\">\n\t\t\t<p><button type=\"button\" class=\"category-mini option_toggle\">-Thyroid<\/button>\n\t\t\t<\/p>\n\t\t\t<div class=\"option_menu\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"option\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Thyroid hormone (Rp304,000)\" \/><span class=\"wpcf7-list-item-label\">Thyroid hormone (Rp304,000)<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"option_dropdown\">\n\t\t\t<p><button type=\"button\" class=\"category-mini option_toggle\">-Female hormones<\/button>\n\t\t\t<\/p>\n\t\t\t<div class=\"option_menu\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"option\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"option[]\" value=\"FSH: follicle-stimulating hormone (Rp639,000)\" \/><span class=\"wpcf7-list-item-label\">FSH: follicle-stimulating hormone (Rp639,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Estradiol (Rp745,000)\" \/><span class=\"wpcf7-list-item-label\">Estradiol (Rp745,000)<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"option_dropdown\">\n\t\t\t<p><button type=\"button\" class=\"category-mini option_toggle\">-Male hormones<\/button>\n\t\t\t<\/p>\n\t\t\t<div class=\"option_menu\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"option\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Testosterone (Rp698,000)\" \/><span class=\"wpcf7-list-item-label\">Testosterone (Rp698,000)<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"option_dropdown\">\n\t\t\t<p><button type=\"button\" class=\"category-mini option_toggle\">-Tumor markers<\/button>\n\t\t\t<\/p>\n\t\t\t<div class=\"option_menu\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"option\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"option[]\" value=\"AFP: liver tumor marker (Rp495,000)\" \/><span class=\"wpcf7-list-item-label\">AFP: liver tumor marker (Rp495,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"CEA: colorectal tumor marker (Rp378,000)\" \/><span class=\"wpcf7-list-item-label\">CEA: colorectal tumor marker (Rp378,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"CA19-9: pancreatic tumor marker (Rp460,000)\" \/><span class=\"wpcf7-list-item-label\">CA19-9: pancreatic tumor marker (Rp460,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"PSA: prostate tumor marker (men) (Rp405,000)\" \/><span class=\"wpcf7-list-item-label\">PSA: prostate tumor marker (men) (Rp405,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"CA125: ovarian tumor marker (women) (Rp489,000)\" \/><span class=\"wpcf7-list-item-label\">CA125: ovarian tumor marker (women) (Rp489,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"CA15-3: breast tumor marker (women) (Rp470,000)\" \/><span class=\"wpcf7-list-item-label\">CA15-3: breast tumor marker (women) (Rp470,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"SCC antigen: squamous cell carcinoma tumor marker (Rp980,000)\" \/><span class=\"wpcf7-list-item-label\">SCC antigen: squamous cell carcinoma tumor marker (Rp980,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"option[]\" value=\"CYFRA21-1: lung tumor marker (Rp873,000)\" \/><span class=\"wpcf7-list-item-label\">CYFRA21-1: lung tumor marker (Rp873,000)<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"option_dropdown\">\n\t\t\t<p><button type=\"button\" class=\"category-mini option_toggle\">-Infectious diseases<\/button>\n\t\t\t<\/p>\n\t\t\t<div class=\"option_menu\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"option\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Anti HAV IgG (Rp900,000)\" \/><span class=\"wpcf7-list-item-label\">Anti HAV IgG (Rp900,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"HBsAg (Qualitative) (Rp70.000)\" \/><span class=\"wpcf7-list-item-label\">HBsAg (Qualitative) (Rp70.000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Anti HBsAg (Qualitative) (Rp83.000)\" \/><span class=\"wpcf7-list-item-label\">Anti HBsAg (Qualitative) (Rp83.000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Anti HCV (Qualitative) (Rp260.000)\" \/><span class=\"wpcf7-list-item-label\">Anti HCV (Qualitative) (Rp260.000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Syphilis test (RPR\/VDRL) (Rp153,000)\" \/><span class=\"wpcf7-list-item-label\">Syphilis test (RPR\/VDRL) (Rp153,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Syphilis test (TPHA) (Rp123,000)\" \/><span class=\"wpcf7-list-item-label\">Syphilis test (TPHA) (Rp123,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Anti HIV (1 method) (Rp350,000)\" \/><span class=\"wpcf7-list-item-label\">Anti HIV (1 method) (Rp350,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"HPV test (Rp1,179,000)\" \/><span class=\"wpcf7-list-item-label\">HPV test (Rp1,179,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"option[]\" value=\"STI PCR test (12 items) (Rp2,250,000)\" \/><span class=\"wpcf7-list-item-label\">STI PCR test (12 items) (Rp2,250,000)<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"option\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Anti Rubella IgG (Rp556.000)\" \/><span class=\"wpcf7-list-item-label\">Anti Rubella IgG (Rp556.000)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Anti Measles IgG (Rp655,000)\" \/><span class=\"wpcf7-list-item-label\">Anti Measles IgG (Rp655,000)<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"option_dropdown\">\n\t\t\t<p><button type=\"button\" class=\"category-mini option_toggle\">-Allergy tests<\/button>\n\t\t\t<\/p>\n\t\t\t<div class=\"option_menu\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"option\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Food allergy test (20 items) (Rp2,470,000)\" \/><span class=\"wpcf7-list-item-label\">Food allergy test (20 items) (Rp2,470,000)<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"option_dropdown option_dropdown_category\">\n\t\t\t<p><button type=\"button\" class=\"category option_toggle option_toggle_category\">Imaging tests<\/button>\n\t\t\t<\/p>\n\t\t\t<div class=\"option_menu\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"option\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Whole abdominal ultrasound (Rp750,000)\" \/><span class=\"wpcf7-list-item-label\">Whole abdominal ultrasound (Rp750,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Upper abdominal ultrasound (Rp550,000)\" \/><span class=\"wpcf7-list-item-label\">Upper abdominal ultrasound (Rp550,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Lower abdominal ultrasound (Rp450,000)\" \/><span class=\"wpcf7-list-item-label\">Lower abdominal ultrasound (Rp450,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Thyroid ultrasound (Rp450,000)\" \/><span class=\"wpcf7-list-item-label\">Thyroid ultrasound (Rp450,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Breast ultrasound (Rp450,000)\" \/><span class=\"wpcf7-list-item-label\">Breast ultrasound (Rp450,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Fluoroscopy (barium test) (Rp1,200,000)\" \/><span class=\"wpcf7-list-item-label\">Fluoroscopy (barium test) (Rp1,200,000)<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"option_dropdown option_dropdown_category\">\n\t\t\t<p><button type=\"button\" class=\"category option_toggle option_toggle_category\">Gynecological tests<\/button>\n\t\t\t<\/p>\n\t\t\t<div class=\"option_menu\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"option\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Cervical cancer cytology (Pap smear method) (Rp260,000)\" \/><span class=\"wpcf7-list-item-label\">Cervical cancer cytology (Pap smear method) (Rp260,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Cervical cancer cytology (ThinPrep method) (Rp887,000)\" \/><span class=\"wpcf7-list-item-label\">Cervical cancer cytology (ThinPrep method) (Rp887,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Breast ultrasound (Rp450,000)\" \/><span class=\"wpcf7-list-item-label\">Breast ultrasound (Rp450,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"CA125: ovarian tumor marker (women) (Rp489,000)\" \/><span class=\"wpcf7-list-item-label\">CA125: ovarian tumor marker (women) (Rp489,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"option[]\" value=\"CA15-3: breast tumor marker (women) (Rp470,000)\" \/><span class=\"wpcf7-list-item-label\">CA15-3: breast tumor marker (women) (Rp470,000)<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"option_dropdown option_dropdown_category\">\n\t\t\t<p><button type=\"button\" class=\"category option_toggle option_toggle_category\">Vaccination<\/button>\n\t\t\t<\/p>\n\t\t\t<div class=\"option_menu\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"option\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Hepatitis A vaccination (adult) (Rp700,000)\" \/><span class=\"wpcf7-list-item-label\">Hepatitis A vaccination (adult) (Rp700,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Hepatitis B vaccination (adult) (Rp510,000)\" \/><span class=\"wpcf7-list-item-label\">Hepatitis B vaccination (adult) (Rp510,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Combined Hepatitis A and B vaccination (Rp850,000)\" \/><span class=\"wpcf7-list-item-label\">Combined Hepatitis A and B vaccination (Rp850,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Tetanus vaccination (Rp250,000)\" \/><span class=\"wpcf7-list-item-label\">Tetanus vaccination (Rp250,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Rabies vaccination (Rp670,000)\" \/><span class=\"wpcf7-list-item-label\">Rabies vaccination (Rp670,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Japanese encephalitis vaccination (Rp710,000)\" \/><span class=\"wpcf7-list-item-label\">Japanese encephalitis vaccination (Rp710,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Influenza vaccination (Rp400,000)\" \/><span class=\"wpcf7-list-item-label\">Influenza vaccination (Rp400,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Dengue fever vaccination (Rp700,000)\" \/><span class=\"wpcf7-list-item-label\">Dengue fever vaccination (Rp700,000)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"option[]\" value=\"Typhoid vaccination (Rp600,000)\" \/><span class=\"wpcf7-list-item-label\">Typhoid vaccination (Rp600,000)<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"formpart\">\n\t<div class=\"formname\">\n\t\t<div class=\"name\">\n\t\t\t<p>Visit history at our clinic\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"require\">\n\t\t\t<p>Required\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"forminput\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"history\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"history\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"history\" value=\"Yes (including all previous visits, including outpatient consultations)\" \/><span class=\"wpcf7-list-item-label\">Yes (including all previous visits, including outpatient consultations)<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"formpart\">\n\t<div class=\"formname\">\n\t\t<div class=\"name\">\n\t\t\t<p>Payment method (plan fee)\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"require\">\n\t\t\t<p>Required\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"forminput\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payment\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"payment\"><option value=\"Please select\">Please select<\/option><option value=\"Pay on the day\">Pay on the day<\/option><option value=\"Company billing\">Company billing<\/option><\/select><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"formpart\">\n\t<div class=\"formname\">\n\t\t<div class=\"name\">\n\t\t\t<p>Payment method (optional tests)\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"require nini\">\n\t\t\t<p>Optional\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"forminput\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payment2\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"payment2\"><option value=\"Please select\">Please select<\/option><option value=\"Pay on the day\">Pay on the day<\/option><option value=\"Company billing\">Company billing<\/option><\/select><\/span>\n\t\t<\/p>\n\t\t<p><br \/>\n[ADD REMARK]\n\t\t<\/p>\n\t\t<p>We accept insurance payments. Please contact us in advance to verify your eligibility and coverage.\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"formpart\">\n\t<div class=\"formname\">\n\t\t<div class=\"name\">\n\t\t\t<p>Company name\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"require nini\">\n\t\t\t<p>Optional\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"forminput\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"company\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"company\" \/><\/span>\n\t\t<\/p>\n\t\t<p class=\"chui_company\">\u203bPlease be sure to enter this if using company billing.\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"formpart\">\n\t<div class=\"formname\">\n\t\t<div class=\"name\">\n\t\t\t<p>Company address\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"require nini\">\n\t\t\t<p>Optional\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"forminput\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"company_address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"company_address\" \/><\/span>\n\t\t<\/p>\n\t\t<p class=\"chui_company\">\u203bPlease be sure to enter this if using company billing.\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"formpart\">\n\t<div class=\"formname\">\n\t\t<div class=\"name\">\n\t\t\t<p>Name of Indonesian accounting contact\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"require nini\">\n\t\t\t<p>Optional\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"forminput\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"keiri_name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"keiri_name\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"formpart\">\n\t<div class=\"formname\">\n\t\t<div class=\"name\">\n\t\t\t<p>Telephone number of Indonesian accounting contact\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"require nini\">\n\t\t\t<p>Optional\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"forminput\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"keiri_tel\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"021-1111-2222\" value=\"\" type=\"text\" name=\"keiri_tel\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"formpart\">\n\t<div class=\"formname\">\n\t\t<div class=\"name\">\n\t\t\t<p>Email address of Indonesian accounting contact\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"require nini\">\n\t\t\t<p>Optional\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"forminput\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"keiri_mail\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" placeholder=\"124@aaa.co.id\" value=\"\" type=\"email\" name=\"keiri_mail\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"formpart\">\n\t<div class=\"formname\">\n\t\t<div class=\"name\">\n\t\t\t<p>Remarks\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"require nini\">\n\t\t\t<p>Optional\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"forminput\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"others\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Please write down any questions or requests you may have.\" name=\"others\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"policy\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"agree\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"agree\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">I agree to <a href=\"https:\/\/dymmedicalclinic.id\/en\/privacypolicy\/\" target=\"_blank\">the Privacy Policy<\/a><\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"submit\">\n\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"submit\" \/>\n\t<\/p>\n<\/div>\n<div class=\"last_chui\">\n\t<p>\u203bAfter submitting the reservation form, our staff will send you a confirmation email within 3 business days.<br \/>\nIf you do not receive a confirmation email, please kindly contact our clinic at <br class=\"pc\" \/>(<a href=\"tel:02186656830\">021-8665-6830<\/a>).\n\t<\/p>\n<\/div>\n<style>\n .option_note {\n margin: 6px 0 10px 28px;\n font-size: 15px;\n color: #555;\n line-height: 1.7;\n }\n\n #form .formpart .formname .require {\n width: 6em;\n }\n<\/style>\n<p><script>\ndocument.addEventListener('wpcf7mailsent', function(event) {\n window.location.href = '\/en\/mcu\/booking-thanks\/';\n}, false);\n<\/script>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":445,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"pages\/booking.php","meta":{"footnotes":""},"acf":[],"_links":{"self":[{"href":"https:\/\/dymmedicalclinic.id\/en\/wp-json\/wp\/v2\/pages\/1034"}],"collection":[{"href":"https:\/\/dymmedicalclinic.id\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/dymmedicalclinic.id\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/dymmedicalclinic.id\/en\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/dymmedicalclinic.id\/en\/wp-json\/wp\/v2\/comments?post=1034"}],"version-history":[{"count":2,"href":"https:\/\/dymmedicalclinic.id\/en\/wp-json\/wp\/v2\/pages\/1034\/revisions"}],"predecessor-version":[{"id":1036,"href":"https:\/\/dymmedicalclinic.id\/en\/wp-json\/wp\/v2\/pages\/1034\/revisions\/1036"}],"up":[{"embeddable":true,"href":"https:\/\/dymmedicalclinic.id\/en\/wp-json\/wp\/v2\/pages\/445"}],"wp:attachment":[{"href":"https:\/\/dymmedicalclinic.id\/en\/wp-json\/wp\/v2\/media?parent=1034"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}