{"id":40,"date":"2014-11-06T12:06:31","date_gmt":"2014-11-06T12:06:31","guid":{"rendered":"http:\/\/217.199.187.192\/astrology.lt\/?page_id=40"},"modified":"2018-02-20T15:40:00","modified_gmt":"2018-02-20T15:40:00","slug":"asmenines-astrologo-konsultacijos","status":"publish","type":"page","link":"http:\/\/www.e-astrology.eu\/en\/asmenines-astrologo-konsultacijos\/","title":{"rendered":"PERSONAL ASTROLOGER\u2019S CONSULTATIONS"},"content":{"rendered":"<div class=\"wpb_row vc_row-fluid \">\n\t<div class=\"vc_span12 wpb_column column_container\">\n\t\t\t<div id=\"mk-custom-box-281\" class=\"mk-custom-boxed mk-blur-parent mk-shortcode  \" style=\"margin-bottom:10px\"><h2 style=\"font-size: 25px;text-align:center;color: #393836;font-weight:bold;margin-top:0px;margin-bottom:18px; \" id=\"fancy-title-737\" class=\"mk-shortcode mk-fancy-title simple-style \"><span style=\"\">\n<p align=\"center\"><b>Personal astrologer\u2019s consultations<\/b><b><\/b><\/p>\n<\/span><\/h2><div class=\"clearboth\"><\/div><div class=\"clearboth\"><\/div><div class=\"mk-shortcode mk-padding-shortcode\" style=\"height:40px\"><\/div><div class=\"clearboth\"><\/div><div class=\"wpb_row vc_row-fluid \">\n\t<div class=\"vc_span6 wpb_column column_container\">\n\t\t\t<div id=\"mk-text-block-972\"  style=\" margin-bottom:0px;text-align: left;\" class=\"mk-text-block  \">Please carefully familiarize yourself with the rules of ordering a horoscope:<br \/>\n1. We provide consultations of the astrologer in an oral and a written form.<br \/>\n2. Consultations in the oral form form be provided:<br \/>\n\u2022 distance (on SKYPE)<br \/>\nor<br \/>\n\u2022 internally (personal meeting with an astrologer, which is being held in Vilnius, Lithuania).<br \/>\n3. Personal oral consultations of an astrologer (SKYPE or during personal meeting) are conducted in the RUSSIAN language only by prior registration and agreement. (The duration of the consultation is up to 1 hour). After receiving the questionnaire, we will contact you to clarify the date and time of the consultation.<br \/>\n4. Horoscopes in WRITTEN form are sent to the specified postal address or e-mail address.<br \/>\n5. If you wish to order a horoscope, you must complete the questionnaire correctly. THE CUSTOMER is responsible for the correctness and accuracy of the data of the questionnaire. An inaccurately completed questionnaire will be the cause of errors in prediction.<br \/>\n6. After we receive your order, we will notify you and confirm by e-mail that your order has been accepted. The requisites for payment will also be stated in the letter.<br \/>\n7. You can pay for the order in any bank (or online) by transferring money to the bank account. Keep the payment receipt or a copy thereof with you. The bank will notify us that you have paid for the order of a horoscope.<br \/>\n8. The order of Horoscope in a written form shall be sent within 10 business days after the reception of the bank\u2019s confirmation of the payment.<br \/>\n9. We guarantee confidentiality of information.<div class=\"clearboth\"><\/div><\/div> \n\t<\/div>\n\t<div class=\"vc_span6 wpb_column column_container\">\n\t\t\t<div class=\"mk-image-shortcode mk-shortcode  align-center simple-frame inside-image \" style=\"max-width: 800px; margin-bottom:10px\"><div class=\"mk-image-inner\"><img class=\"lightbox-false\" alt=\"\" title=\"\" src=\"http:\/\/www.e-astrology.eu\/en\/wp-content\/uploads\/thumb-cache\/77-3589a260f9cb3a1bec500c1a10ba085e-800x200-100-crop.jpeg\" \/><\/div><div class=\"clearboth\"><\/div><\/div>\n\t<\/div><\/div><div class=\"wpb_row vc_row-fluid \">\n\t<div class=\"vc_span12 wpb_column column_container\">\n\t\t\t<div id=\"mk-text-block-673\"  style=\" margin-bottom:0px;text-align: left;\" class=\"mk-text-block  \">\n<style>\r\n.form-select {\r\n\tlist-style-type:none; \r\n\tmargin-left: 0px;\r\n}\r\n\r\n.form-select li {\r\n\tmargin-left: 0;\r\n}\r\n\r\n.form-select li span {\r\n\tcursor: pointer;\r\n\tcolor: rgb(102, 34, 75);\r\n\ttext-decoration: underline;\r\n\tfont-size: 15px;\r\n\tfont-weight: 700;\r\n}\r\n\r\n.form-select li a.actyve {\r\n\t\tfont-weight: bold;\r\n}\r\n.form-select li p {\r\n    margin-bottom: 5px;\r\n    padding-left: 16px;\r\n\r\n}\r\n.hidden-form {\r\n\tdisplay: none;\r\n}\r\n.form-switch {\r\n\tdisplay: none;\r\n}\r\n\r\n.form-preloader {\r\n    text-align:  center;\r\n    margin-top: 50px;\r\n    height: 500px;\r\n}\r\n\r\n.form-preloader img {\r\n    width:35px\r\n}\r\n<\/style>\r\n<div class=\"form-preloader\">\r\n\t<img src=\"http:\/\/www.e-astrology.eu\/en\/wp-content\/themes\/jupiter\/images\/prel.gif\"\/>\r\n<\/div>\r\n<div class=\"form-switch\">\r\n\t<ul class=\"form-select\">\r\n\t\t<li>\r\n\t\t\t<input type=\"radio\" name='horoscop' value=\"AH\"> <span>Personal horoscope <\/span>\r\n\t\t\t<p>\r\n\t\t\t\t(psychological portrait, strengths and weaknesses of one\u2019s character, talent, abilities, interests, professional orientation, internal potential, etc.)\r\n\t\t\t<\/p>\t\r\n\t\t<\/li>\r\n\t\t<li>\r\n\t\t\t<input type=\"radio\" name='horoscop' value=\"AP\"> <span>Astrological prediction<\/span>\r\n\t\t\t<p>\r\n\t\t\t\t\t(events in life, opportunities and obstacles, how to avoid conflicts, perspectives of relationships)\r\n\t\t\t<\/p>\t\r\n\t\t<\/li>\r\n\t\t<li>\r\n\t\t\t<input type=\"radio\" name='horoscop' value=\"PS\"> <span>Compatibility horoscope<\/span>\r\n\t\t\t<p>\r\n\t\t\t\t\t(your compatibility with the partner, difficulties of mutual relationship, how to avoid conflicts, perspectives of relationships)\r\n\t\t\t<\/p>\r\n\t\t<\/li>\r\n\t\t<li>\r\n\t\t\t<input type=\"radio\" name='horoscop' value=\"VH\"> <span>Children\u2019s horoscope<\/span>\r\n\t\t\t<p>\r\n\t\t\t\t\t(We can say a lot about your child, we will help you find out his\/her psychological peculiarities and give you some pieces of advice and recommendations which will help you avoid upbringing mistakes.)\r\n\t\t\t<\/p>\r\n\t\t<\/li>\r\n\t\t<li>\r\n\t\t\t<input type=\"radio\" name='horoscop' value=\"MH\"> <span>Medical horoscope<\/span>\r\n\t\t\t<p>\r\n\t\t\t\t\t(causes of existing and future diseases, inclination for diseases, a natural organism condition improvement program, recommendations for improving your health, selection of the best time for treatment or surgery)\r\n\t\t\t<\/p>\r\n\t\t<\/li>\r\n\t<\/ul>\r\n\r\n\t<div class=\"hidden-form form-AH\">\r\n\t<div id=\"iphorm-outer-6acc3aa32c68c\" class=\"iphorm-outer iphorm-outer-1 iphorm-uniform-theme-default iphorm-theme-light-light iphorm-has-logic\" >\n    <script type=\"text\/javascript\">\n        jQuery(document).ready(function($) {\n                            iPhorm.logic[1] = {\"logic\":{\"14\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"13\",\"operator\":\"eq\",\"value\":\"Secondary-special\"},{\"element_id\":\"13\",\"operator\":\"eq\",\"value\":\"Higher\"}]},\"16\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"15\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"20\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"19\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"23\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"22\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"24\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"22\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"26\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By e-mail\"}]},\"28\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail 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               },\n                    show: {\n                        event: 'click'\n                    },\n                    hide: {\n                        event: 'unfocus'\n                    },\n                    content: {\n                        text: function (api) {\n                            return $(this).find('.iphorm-tooltip-icon-content').html();\n                        }\n                    }\n                });\n                $('.iphorm-labels-inside > .iphorm-element-spacer > label').hover(function () {\n                    $(this).siblings('.iphorm-input-wrap').find('.iphorm-tooltip-hover').qtip('show');\n                }, function () {\n                    $(this).siblings('.iphorm-input-wrap').find('.iphorm-tooltip-hover').qtip('hide');\n                });\n            }\n                                    if ($.isFunction($.fn.uniform)) {\n                $('select, input:checkbox, input:radio', iPhorm.instance.$form).uniform({context: iPhorm.instance.$form, selectAutoWidth: false});\n            }\n                        if ($.isFunction($.fn.inFieldLabels)) {\n                $('.iphorm-labels-inside:not(.iphorm-element-wrap-recaptcha) > .iphorm-element-spacer > label', iPhorm.instance.$form).inFieldLabels();\n            }\n                        $('.iphorm-group-row > div:last-child:not(:first-child)', iPhorm.instance.$form).add('.iphorm-group-row:last-child', iPhorm.instance.$form).addClass('last-child');\n                            iPhorm.instance.applyAllLogic(true);\n                $('#iphorm-outer-6acc3aa32c68c').css('visibility', 'visible');\n                    });\n    <\/script>\n    <form id=\"iphorm-6acc3aa32c68c\" class=\"iphorm iphorm-form-1\" action=\"\/en\/wp-json\/wp\/v2\/pages\/40#iphorm-6acc3aa32c68c\" method=\"post\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\">\n        <div class=\"iphorm-inner iphorm-inner-1\" >\n            <input type=\"hidden\" name=\"iphorm_id\" value=\"1\" \/>\n            <input type=\"hidden\" name=\"iphorm_uid\" value=\"6acc3aa32c68c\" \/>\n            <input type=\"hidden\" name=\"form_url\" value=\"http:\/\/www.e-astrology.eu\/en\/wp-json\/wp\/v2\/pages\/40\" \/>\n            <input type=\"hidden\" name=\"referring_url\" value=\"\" \/>\n            <input type=\"hidden\" name=\"post_id\" value=\"\" \/>\n            <input type=\"hidden\" name=\"post_title\" value=\"\" \/>\n                            <h3 class=\"iphorm-title\" >PERSONAL HOROSCOPE \u2013 ORDER FORM<\/h3>\n                                                <div class=\"iphorm-elements iphorm-elements-1 iphorm-clearfix\" >\n                Attention! Please complete all boxes of the questionnaire very carefully. We guarantee that all information stated in the registration form and information concerning your horoscope is confidential and it shall not be disclosed to any third parties in any case.\n<br><\/br><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_1_38-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_1_38-element-spacer\">\n        <label class=\"iphorm_1_38-outer-label\" >Type (kind) of ORAL consultation:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_1_38-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_1_38-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_38-input-li\" >\n                    <label for=\"iphorm_1_38_6acc3aa32c68c_1\"  class=\"iphorm_1_38_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_38 iphorm_1_38_1\" type=\"checkbox\" name=\"iphorm_1_38[]\" id=\"iphorm_1_38_6acc3aa32c68c_1\" value=\"Consultation on SKYPE (cost 50 eur)\"  \/>\n                        Consultation on SKYPE (cost 50 eur)                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_38-input-li\" >\n                    <label for=\"iphorm_1_38_6acc3aa32c68c_2\"  class=\"iphorm_1_38_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_38 iphorm_1_38_2\" type=\"checkbox\" name=\"iphorm_1_38[]\" id=\"iphorm_1_38_6acc3aa32c68c_2\" value=\"Personal visit\/meeting (only in Vilnius, Lithuania)\"  \/>\n                        Personal visit\/meeting (only in Vilnius, Lithuania)                    <\/label>\n                <\/div>\n                        <\/div>\n                <p class=\"iphorm-description\" >Attention! The cost of personal consultation (meeting with the astrologer) is determined individually.<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_1_39-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_1_39-element-spacer\">\n        <label class=\"iphorm_1_39-outer-label\" >Order of the Horoscope in a written form:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_1_39-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_1_39-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_39-input-li\" >\n                    <label for=\"iphorm_1_39_6acc3aa32c68c_1\"  class=\"iphorm_1_39_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_39 iphorm_1_39_1\" type=\"checkbox\" name=\"iphorm_1_39[]\" id=\"iphorm_1_39_6acc3aa32c68c_1\" value=\"I want to order the Horoscope in a WRITTEN form\"  \/>\n                        I want to order the Horoscope in a WRITTEN form                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_1_34-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_1_34-element-spacer\">\n        <label class=\"iphorm_1_34-outer-label\" >I want to order the horoscope:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_1_34-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_1_34-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_34-input-li\" >\n                    <label for=\"iphorm_1_34_6acc3aa32c68c_1\"  class=\"iphorm_1_34_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_34 iphorm_1_34_1\" type=\"checkbox\" name=\"iphorm_1_34[]\" id=\"iphorm_1_34_6acc3aa32c68c_1\" value=\"in English Language \u2013 120 eur.\"  \/>\n                        in English Language \u2013 120 eur.                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_34-input-li\" >\n                    <label for=\"iphorm_1_34_6acc3aa32c68c_2\"  class=\"iphorm_1_34_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_34 iphorm_1_34_2\" type=\"checkbox\" name=\"iphorm_1_34[]\" id=\"iphorm_1_34_6acc3aa32c68c_2\" value=\"in Russian Language \u2013 60 eur.\"  \/>\n                        in Russian Language \u2013 60 eur.                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_34-input-li\" >\n                    <label for=\"iphorm_1_34_6acc3aa32c68c_3\"  class=\"iphorm_1_34_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_34 iphorm_1_34_3\" type=\"checkbox\" name=\"iphorm_1_34[]\" id=\"iphorm_1_34_6acc3aa32c68c_3\" value=\"in Lithuanian Language \u2013 120 eur.\"  \/>\n                        in Lithuanian Language \u2013 120 eur.                    <\/label>\n                <\/div>\n                        <\/div>\n                <p class=\"iphorm-description\" >The cost of a written horoscope depends on the chosen language<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_1_2-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_1_2-element-spacer\">\n        <label for=\"iphorm_1_2_6acc3aa32c68c\" class=\"iphorm_1_2-outer-label\" >Name and surname:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_1_2-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_1_2\" id=\"iphorm_1_2_6acc3aa32c68c\" type=\"text\" name=\"iphorm_1_2\"  value=\"\"  \/>\n                <p class=\"iphorm-description\" >* We need your name and surname to check and receive the bank transfer (payment of your order).<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_1_3-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_1_3-element-spacer\">\n        <label class=\"iphorm_1_3-outer-label\" >Sex:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_1_3-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_1_3-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_3-input-li\" >\n                    <label for=\"iphorm_1_3_6acc3aa32c68c_1\"  class=\"iphorm_1_3_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_3 iphorm_1_3_1\" type=\"checkbox\" name=\"iphorm_1_3[]\" id=\"iphorm_1_3_6acc3aa32c68c_1\" value=\"Male\"  \/>\n                        Male                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_3-input-li\" >\n                    <label for=\"iphorm_1_3_6acc3aa32c68c_2\"  class=\"iphorm_1_3_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_3 iphorm_1_3_2\" type=\"checkbox\" name=\"iphorm_1_3[]\" id=\"iphorm_1_3_6acc3aa32c68c_2\" value=\"Female\"  \/>\n                        Female                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-date iphorm_1_4-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\r\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-date iphorm_1_4-element-spacer\">\r\n        <label id=\"iphorm_1_4_6acc3aa32c68c_date_label\" class=\"iphorm_1_4-outer-label\" >Date of birth:<\/label>        <div id=\"iphorm_1_4_6acc3aa32c68c\" class=\"iphorm-input-wrap iphorm-input-wrap-date iphorm_1_4-input-wrap\" >\r\n        \t<div class=\"iphorm-clearfix\">\r\n                <div class=\"iphorm-input-wrap-date-select-wrap\">\r\n                                                                                <label id=\"iphorm_1_4_6acc3aa32c68c_day_label\" class=\"iphorm-screen-reader-text\">Day<\/label>\r\n                    <select id=\"iphorm_1_4_6acc3aa32c68c_day\" name=\"iphorm_1_4[day]\" class=\"iphorm_1_4-input-day\" aria-labelledby=\"iphorm_1_4_6acc3aa32c68c_date_label iphorm_1_4_6acc3aa32c68c_day_label\" >\r\n                        <option value=\"\">Day<\/option>                                                    <option value=\"1\" >1<\/option>\r\n                                                    <option value=\"2\" >2<\/option>\r\n                                                    <option value=\"3\" >3<\/option>\r\n                                                    <option value=\"4\" >4<\/option>\r\n                                                    <option value=\"5\" >5<\/option>\r\n                                                    <option value=\"6\" >6<\/option>\r\n                                                    <option value=\"7\" >7<\/option>\r\n                                                    <option value=\"8\" >8<\/option>\r\n                                                    <option value=\"9\" >9<\/option>\r\n                                                    <option value=\"10\" >10<\/option>\r\n                                                    <option value=\"11\" >11<\/option>\r\n                                                    <option value=\"12\" >12<\/option>\r\n                                                    <option value=\"13\" >13<\/option>\r\n                                                    <option value=\"14\" >14<\/option>\r\n                                                    <option value=\"15\" >15<\/option>\r\n                                                    <option value=\"16\" >16<\/option>\r\n                                                    <option value=\"17\" >17<\/option>\r\n                                                    <option value=\"18\" >18<\/option>\r\n                                                    <option value=\"19\" >19<\/option>\r\n                                                    <option value=\"20\" >20<\/option>\r\n                                                    <option value=\"21\" >21<\/option>\r\n                                                    <option value=\"22\" >22<\/option>\r\n                                                    <option value=\"23\" >23<\/option>\r\n                                                    <option value=\"24\" >24<\/option>\r\n                                                    <option value=\"25\" >25<\/option>\r\n                                                    <option value=\"26\" >26<\/option>\r\n                                                    <option value=\"27\" >27<\/option>\r\n                                                    <option value=\"28\" >28<\/option>\r\n                                                    <option value=\"29\" >29<\/option>\r\n                                                    <option value=\"30\" >30<\/option>\r\n                                                    <option value=\"31\" >31<\/option>\r\n                                            <\/select>\r\n                                        <label id=\"iphorm_1_4_6acc3aa32c68c_month_label\" class=\"iphorm-screen-reader-text\">Month<\/label>\r\n                    <select id=\"iphorm_1_4_6acc3aa32c68c_month\" name=\"iphorm_1_4[month]\" class=\"iphorm_1_4-input-month\" aria-labelledby=\"iphorm_1_4_6acc3aa32c68c_date_label iphorm_1_4_6acc3aa32c68c_month_label\" >\r\n                        <option value=\"\">Month<\/option>                                                    <option value=\"1\" >1<\/option>\r\n                                                    <option value=\"2\" >2<\/option>\r\n                                                    <option value=\"3\" >3<\/option>\r\n                                                    <option value=\"4\" >4<\/option>\r\n                                                    <option value=\"5\" >5<\/option>\r\n                                                    <option value=\"6\" >6<\/option>\r\n                                                    <option value=\"7\" >7<\/option>\r\n                                                    <option value=\"8\" >8<\/option>\r\n                                                    <option value=\"9\" >9<\/option>\r\n                                                    <option value=\"10\" >10<\/option>\r\n                                                    <option value=\"11\" >11<\/option>\r\n                                                    <option value=\"12\" >12<\/option>\r\n                                            <\/select>\r\n                                        <label id=\"iphorm_1_4_6acc3aa32c68c_year_label\" class=\"iphorm-screen-reader-text\">Year<\/label>\r\n                    <select id=\"iphorm_1_4_6acc3aa32c68c_year\" name=\"iphorm_1_4[year]\" class=\"iphorm_1_4-input-year\" aria-labelledby=\"iphorm_1_4_6acc3aa32c68c_date_label iphorm_1_4_6acc3aa32c68c_year_label\" >\r\n                        <option value=\"\">Year<\/option>                                                                                    <option value=\"2030\" >2030<\/option>\r\n                                                            <option value=\"2029\" >2029<\/option>\r\n                                                            <option value=\"2028\" >2028<\/option>\r\n                                                            <option value=\"2027\" >2027<\/option>\r\n                                                            <option value=\"2026\" >2026<\/option>\r\n                                                            <option value=\"2025\" >2025<\/option>\r\n                                                            <option value=\"2024\" >2024<\/option>\r\n                                                            <option value=\"2023\" >2023<\/option>\r\n                                                            <option value=\"2022\" >2022<\/option>\r\n                                                            <option value=\"2021\" >2021<\/option>\r\n                                                            <option value=\"2020\" >2020<\/option>\r\n                                                            <option value=\"2019\" >2019<\/option>\r\n                                                            <option value=\"2018\" >2018<\/option>\r\n                                                            <option value=\"2017\" >2017<\/option>\r\n                                                            <option value=\"2016\" >2016<\/option>\r\n                                                            <option value=\"2015\" >2015<\/option>\r\n                                                            <option value=\"2014\" >2014<\/option>\r\n                                                            <option value=\"2013\" >2013<\/option>\r\n                                                            <option value=\"2012\" >2012<\/option>\r\n                                                            <option value=\"2011\" >2011<\/option>\r\n                                                            <option value=\"2010\" >2010<\/option>\r\n                                                            <option value=\"2009\" >2009<\/option>\r\n                                                            <option value=\"2008\" >2008<\/option>\r\n                                                            <option value=\"2007\" >2007<\/option>\r\n                                                            <option value=\"2006\" >2006<\/option>\r\n                                                            <option value=\"2005\" >2005<\/option>\r\n                                                            <option value=\"2004\" >2004<\/option>\r\n                                                            <option value=\"2003\" >2003<\/option>\r\n                                                            <option value=\"2002\" >2002<\/option>\r\n                                                            <option value=\"2001\" >2001<\/option>\r\n                                                            <option value=\"2000\" >2000<\/option>\r\n                                                            <option value=\"1999\" >1999<\/option>\r\n                                                            <option value=\"1998\" >1998<\/option>\r\n                                                            <option value=\"1997\" >1997<\/option>\r\n                                                            <option value=\"1996\" >1996<\/option>\r\n                                                            <option value=\"1995\" >1995<\/option>\r\n                                                            <option value=\"1994\" >1994<\/option>\r\n                                                            <option value=\"1993\" >1993<\/option>\r\n                                                            <option value=\"1992\" >1992<\/option>\r\n                                                            <option value=\"1991\" >1991<\/option>\r\n                                                            <option value=\"1990\" >1990<\/option>\r\n                                                            <option value=\"1989\" >1989<\/option>\r\n                                                            <option value=\"1988\" >1988<\/option>\r\n                                                            <option value=\"1987\" >1987<\/option>\r\n                                                            <option value=\"1986\" >1986<\/option>\r\n                                                            <option value=\"1985\" >1985<\/option>\r\n                                                            <option value=\"1984\" >1984<\/option>\r\n                                                            <option value=\"1983\" >1983<\/option>\r\n                                                            <option value=\"1982\" >1982<\/option>\r\n                                                            <option value=\"1981\" >1981<\/option>\r\n                                                            <option value=\"1980\" >1980<\/option>\r\n                                                            <option value=\"1979\" >1979<\/option>\r\n                                                            <option value=\"1978\" >1978<\/option>\r\n                                                            <option value=\"1977\" >1977<\/option>\r\n                                                            <option value=\"1976\" >1976<\/option>\r\n                                                            <option value=\"1975\" >1975<\/option>\r\n                                                            <option value=\"1974\" >1974<\/option>\r\n                                                            <option value=\"1973\" >1973<\/option>\r\n                                                            <option value=\"1972\" >1972<\/option>\r\n                                                            <option value=\"1971\" >1971<\/option>\r\n                                                            <option value=\"1970\" >1970<\/option>\r\n                                                            <option value=\"1969\" >1969<\/option>\r\n                                                            <option value=\"1968\" >1968<\/option>\r\n                                                            <option value=\"1967\" >1967<\/option>\r\n                                                            <option value=\"1966\" >1966<\/option>\r\n                                                            <option value=\"1965\" >1965<\/option>\r\n                                                            <option value=\"1964\" >1964<\/option>\r\n                                                            <option value=\"1963\" >1963<\/option>\r\n                                                            <option value=\"1962\" >1962<\/option>\r\n                                                            <option value=\"1961\" >1961<\/option>\r\n                                                            <option value=\"1960\" >1960<\/option>\r\n                                                            <option value=\"1959\" >1959<\/option>\r\n                                                            <option value=\"1958\" >1958<\/option>\r\n                                                            <option value=\"1957\" >1957<\/option>\r\n                                                            <option value=\"1956\" >1956<\/option>\r\n                                                            <option value=\"1955\" >1955<\/option>\r\n                                                            <option value=\"1954\" >1954<\/option>\r\n                                                            <option value=\"1953\" >1953<\/option>\r\n                                                            <option value=\"1952\" >1952<\/option>\r\n                                                            <option value=\"1951\" >1951<\/option>\r\n                                                            <option value=\"1950\" >1950<\/option>\r\n                                                            <option value=\"1949\" >1949<\/option>\r\n                                                            <option value=\"1948\" >1948<\/option>\r\n                                                            <option value=\"1947\" >1947<\/option>\r\n                                                            <option value=\"1946\" >1946<\/option>\r\n                                                            <option value=\"1945\" >1945<\/option>\r\n                                                            <option value=\"1944\" >1944<\/option>\r\n                                                            <option value=\"1943\" >1943<\/option>\r\n                                                            <option value=\"1942\" >1942<\/option>\r\n                                                            <option value=\"1941\" >1941<\/option>\r\n                                                            <option value=\"1940\" >1940<\/option>\r\n                                                            <option value=\"1939\" >1939<\/option>\r\n                                                            <option value=\"1938\" >1938<\/option>\r\n                                                            <option value=\"1937\" >1937<\/option>\r\n                                                            <option value=\"1936\" >1936<\/option>\r\n                                                            <option value=\"1935\" >1935<\/option>\r\n                                                            <option value=\"1934\" >1934<\/option>\r\n                                                            <option value=\"1933\" >1933<\/option>\r\n                                                            <option value=\"1932\" >1932<\/option>\r\n                                                            <option value=\"1931\" >1931<\/option>\r\n                                                            <option value=\"1930\" >1930<\/option>\r\n                                                            <option value=\"1929\" >1929<\/option>\r\n                                                            <option value=\"1928\" >1928<\/option>\r\n                                                            <option value=\"1927\" >1927<\/option>\r\n                                                            <option value=\"1926\" >1926<\/option>\r\n                                                            <option value=\"1925\" >1925<\/option>\r\n                                                            <option value=\"1924\" >1924<\/option>\r\n                                                            <option value=\"1923\" >1923<\/option>\r\n                                                            <option value=\"1922\" >1922<\/option>\r\n                                                            <option value=\"1921\" >1921<\/option>\r\n                                                            <option value=\"1920\" >1920<\/option>\r\n                                                            <option value=\"1919\" >1919<\/option>\r\n                                                            <option value=\"1918\" >1918<\/option>\r\n                                                            <option value=\"1917\" >1917<\/option>\r\n                                                            <option value=\"1916\" >1916<\/option>\r\n                                                            <option value=\"1915\" >1915<\/option>\r\n                                                            <option value=\"1914\" >1914<\/option>\r\n                                                            <option value=\"1913\" >1913<\/option>\r\n                                                            <option value=\"1912\" >1912<\/option>\r\n                                                            <option value=\"1911\" >1911<\/option>\r\n                                                            <option value=\"1910\" >1910<\/option>\r\n                                                            <option value=\"1909\" >1909<\/option>\r\n                                                            <option value=\"1908\" >1908<\/option>\r\n                                                            <option value=\"1907\" >1907<\/option>\r\n                                                            <option value=\"1906\" >1906<\/option>\r\n                                                            <option value=\"1905\" >1905<\/option>\r\n                                                            <option value=\"1904\" >1904<\/option>\r\n                                                            <option value=\"1903\" >1903<\/option>\r\n                                                            <option value=\"1902\" >1902<\/option>\r\n                                                            <option value=\"1901\" >1901<\/option>\r\n                                                            <option value=\"1900\" >1900<\/option>\r\n                                                                        <\/select>\r\n                <\/div>\r\n                            <\/div>\r\n                    <\/div>\r\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\r\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-time iphorm_1_5-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-time iphorm_1_5-element-spacer\">\n        <label id=\"iphorm_1_5_6acc3aa32c68c_time_label\" class=\"iphorm_1_5-outer-label\" >Exact time of birth (hours and minutes):<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-date iphorm_1_5-input-wrap\" >\n            <label id=\"iphorm_1_5_6acc3aa32c68c_hour_label\" class=\"iphorm-screen-reader-text\">Hour<\/label>\n            <select id=\"iphorm_1_5_6acc3aa32c68c_hour\"  name=\"iphorm_1_5[hour]\" class=\"iphorm_1_5-input-hour\" aria-labelledby=\"iphorm_1_5_6acc3aa32c68c_time_label iphorm_1_5_6acc3aa32c68c_hour_label\" >\n                <option value=\"\">HH<\/option>                                                                                    <option value=\"00\" >00<\/option>\n                                                                    <option value=\"01\" >01<\/option>\n                                                                    <option value=\"02\" >02<\/option>\n                                                                    <option value=\"03\" >03<\/option>\n                                                                    <option value=\"04\" >04<\/option>\n                                                                    <option value=\"05\" >05<\/option>\n                                                                    <option value=\"06\" >06<\/option>\n                                                                    <option value=\"07\" >07<\/option>\n                                                                    <option value=\"08\" >08<\/option>\n                                                                    <option value=\"09\" >09<\/option>\n                                                                    <option value=\"10\" >10<\/option>\n                                                                    <option value=\"11\" >11<\/option>\n                                                                    <option value=\"12\"  selected='selected'>12<\/option>\n                                                                    <option value=\"13\" >13<\/option>\n                                                                    <option value=\"14\" >14<\/option>\n                                                                    <option value=\"15\" >15<\/option>\n                                                                    <option value=\"16\" >16<\/option>\n                                                                    <option value=\"17\" >17<\/option>\n                                                                    <option value=\"18\" >18<\/option>\n                                                                    <option value=\"19\" >19<\/option>\n                                                                    <option value=\"20\" >20<\/option>\n                                                                    <option value=\"21\" >21<\/option>\n                                                                    <option value=\"22\" >22<\/option>\n                                                                    <option value=\"23\" >23<\/option>\n                                                <\/select>\n            <label id=\"iphorm_1_5_6acc3aa32c68c_minute_label\" class=\"iphorm-screen-reader-text\">Minute<\/label>\n            <select id=\"iphorm_1_5_6acc3aa32c68c_minute\" name=\"iphorm_1_5[minute]\" class=\"iphorm_1_5-input-minute\" aria-labelledby=\"iphorm_1_5_6acc3aa32c68c_time_label iphorm_1_5_6acc3aa32c68c_minute_label\" >\n                <option value=\"\">MM<\/option>                                                                                    <option value=\"00\"  selected='selected'>00<\/option>\n                                                                                                        <option value=\"01\" >01<\/option>\n                                                                                                        <option value=\"02\" >02<\/option>\n                                                                                                        <option value=\"03\" >03<\/option>\n                                                                                                        <option value=\"04\" >04<\/option>\n                                                                                                        <option value=\"05\" >05<\/option>\n                                                                                                        <option value=\"06\" >06<\/option>\n                                                                                                        <option value=\"07\" >07<\/option>\n                                                                                                        <option value=\"08\" >08<\/option>\n                                                                                                        <option value=\"09\" >09<\/option>\n                                                                                                        <option value=\"10\" >10<\/option>\n                                                                                                        <option value=\"11\" >11<\/option>\n                                                                                                        <option value=\"12\" >12<\/option>\n                                                                                                        <option value=\"13\" >13<\/option>\n                                                                                                        <option value=\"14\" >14<\/option>\n                                                                                                        <option value=\"15\" >15<\/option>\n                                                                                                        <option value=\"16\" >16<\/option>\n                                                                                                        <option value=\"17\" >17<\/option>\n                                                                                                        <option value=\"18\" >18<\/option>\n                                                                                                        <option value=\"19\" >19<\/option>\n                                                                                                        <option value=\"20\" >20<\/option>\n                                                                                                        <option value=\"21\" >21<\/option>\n                                                                                                        <option value=\"22\" >22<\/option>\n                                                                                                        <option value=\"23\" >23<\/option>\n                                                                                                        <option value=\"24\" >24<\/option>\n                                                                                                        <option value=\"25\" >25<\/option>\n                                                                                                        <option value=\"26\" >26<\/option>\n                                                                                                        <option value=\"27\" >27<\/option>\n                                                                                                        <option value=\"28\" >28<\/option>\n                                                                                                        <option value=\"29\" >29<\/option>\n                                                                                                        <option value=\"30\" >30<\/option>\n                                                                                                        <option value=\"31\" >31<\/option>\n                                                                                                        <option value=\"32\" >32<\/option>\n                                                                                                        <option value=\"33\" >33<\/option>\n                                                                                                        <option value=\"34\" >34<\/option>\n                                                                                                        <option value=\"35\" >35<\/option>\n                                                                                                        <option value=\"36\" >36<\/option>\n                                                                                                        <option value=\"37\" >37<\/option>\n                                                                                                        <option value=\"38\" >38<\/option>\n                                                                                                        <option value=\"39\" >39<\/option>\n                                                                                                        <option value=\"40\" >40<\/option>\n                                                                                                        <option value=\"41\" >41<\/option>\n                                                                                                        <option value=\"42\" >42<\/option>\n                                                                                                        <option value=\"43\" >43<\/option>\n                                                                                                        <option value=\"44\" >44<\/option>\n                                                                                                        <option value=\"45\" >45<\/option>\n                                                                                                        <option value=\"46\" >46<\/option>\n                                                                                                        <option value=\"47\" >47<\/option>\n                                                                                                        <option value=\"48\" >48<\/option>\n                                                                                                        <option value=\"49\" >49<\/option>\n                                                                                                        <option value=\"50\" >50<\/option>\n                                                                                                        <option value=\"51\" >51<\/option>\n                                                                                                        <option value=\"52\" >52<\/option>\n                                                                                                        <option value=\"53\" >53<\/option>\n                                                                                                        <option value=\"54\" >54<\/option>\n                                                                                                        <option value=\"55\" >55<\/option>\n                                                                                                        <option value=\"56\" >56<\/option>\n                                                                                                        <option value=\"57\" >57<\/option>\n                                                                                                        <option value=\"58\" >58<\/option>\n                                                                                                        <option value=\"59\" >59<\/option>\n                                                <\/select>\n                            <input type=\"hidden\" name=\"iphorm_1_5[ampm]\" value=\"\" \/>\n                                <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_1_6-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_1_6-element-spacer\">\n        <label class=\"iphorm_1_6-outer-label\" >If you don\u2019t know the exact time of birth, enter the approximate time and tick this box:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_1_6-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_1_6-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_6-input-li\" >\n                    <label for=\"iphorm_1_6_6acc3aa32c68c_1\"  class=\"iphorm_1_6_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_6 iphorm_1_6_1\" type=\"checkbox\" name=\"iphorm_1_6[]\" id=\"iphorm_1_6_6acc3aa32c68c_1\" value=\"I know the approximate time of birth only.\"  \/>\n                        I know the approximate time of birth only.                    <\/label>\n                <\/div>\n                        <\/div>\n                <p class=\"iphorm-description\" >Attention! If you don\u2019t know the exact time of birth, predictions may be inaccurate. The approximate time of birth can be stated for psychological and compatibility horoscopes. The more exact time of birth is stated, the more accurate the prediction is!<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_1_9-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_1_9-element-spacer\">\n        <label for=\"iphorm_1_9_6acc3aa32c68c\" class=\"iphorm_1_9-outer-label\" >Exact country of birth:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_1_9-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_1_9\" id=\"iphorm_1_9_6acc3aa32c68c\" type=\"text\" name=\"iphorm_1_9\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_1_10-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_1_10-element-spacer\">\n        <label for=\"iphorm_1_10_6acc3aa32c68c\" class=\"iphorm_1_10-outer-label\" >Exact city of birth:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_1_10-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_1_10\" id=\"iphorm_1_10_6acc3aa32c68c\" type=\"text\" name=\"iphorm_1_10\"  value=\"\"  \/>\n                <p class=\"iphorm-description\" >(If you were born in a small settlement, state the closest city.)<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_1_11-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_1_11-element-spacer\">\n        <label for=\"iphorm_1_11_6acc3aa32c68c\" class=\"iphorm_1_11-outer-label\" >Country where you live in now:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_1_11-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_1_11\" id=\"iphorm_1_11_6acc3aa32c68c\" type=\"text\" name=\"iphorm_1_11\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_1_12-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_1_12-element-spacer\">\n        <label for=\"iphorm_1_12_6acc3aa32c68c\" class=\"iphorm_1_12-outer-label\" >City where you live in now:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_1_12-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_1_12\" id=\"iphorm_1_12_6acc3aa32c68c\" type=\"text\" name=\"iphorm_1_12\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_1_13-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_1_13-element-spacer\">\n        <label class=\"iphorm_1_13-outer-label\" >Your education:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_1_13-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_1_13-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_13-input-li\" >\n                    <label for=\"iphorm_1_13_6acc3aa32c68c_1\"  class=\"iphorm_1_13_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_13 iphorm_1_13_1\" type=\"checkbox\" name=\"iphorm_1_13[]\" id=\"iphorm_1_13_6acc3aa32c68c_1\" value=\"Secondary\"  \/>\n                        Secondary                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_13-input-li\" >\n                    <label for=\"iphorm_1_13_6acc3aa32c68c_2\"  class=\"iphorm_1_13_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_13 iphorm_1_13_2\" type=\"checkbox\" name=\"iphorm_1_13[]\" id=\"iphorm_1_13_6acc3aa32c68c_2\" value=\"Secondary-special\"  \/>\n                        Secondary-special                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_13-input-li\" >\n                    <label for=\"iphorm_1_13_6acc3aa32c68c_3\"  class=\"iphorm_1_13_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_13 iphorm_1_13_3\" type=\"checkbox\" name=\"iphorm_1_13[]\" id=\"iphorm_1_13_6acc3aa32c68c_3\" value=\"Higher\"  \/>\n                        Higher                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_1_14-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_1_14-element-spacer\">\n        <label for=\"iphorm_1_14_6acc3aa32c68c\" class=\"iphorm_1_14-outer-label\" >State the speciality:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_1_14-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_1_14\" id=\"iphorm_1_14_6acc3aa32c68c\" type=\"text\" name=\"iphorm_1_14\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_1_15-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_1_15-element-spacer\">\n        <label class=\"iphorm_1_15-outer-label\" >Are you employed at the moment?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_1_15-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_1_15-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_15-input-li\" >\n                    <label for=\"iphorm_1_15_6acc3aa32c68c_1\"  class=\"iphorm_1_15_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_15 iphorm_1_15_1\" type=\"checkbox\" name=\"iphorm_1_15[]\" id=\"iphorm_1_15_6acc3aa32c68c_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_15-input-li\" >\n                    <label for=\"iphorm_1_15_6acc3aa32c68c_2\"  class=\"iphorm_1_15_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_15 iphorm_1_15_2\" type=\"checkbox\" name=\"iphorm_1_15[]\" id=\"iphorm_1_15_6acc3aa32c68c_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_1_16-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_1_16-element-spacer\">\n        <label for=\"iphorm_1_16_6acc3aa32c68c\" class=\"iphorm_1_16-outer-label\" >Your profession:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_1_16-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_1_16\" id=\"iphorm_1_16_6acc3aa32c68c\" type=\"text\" name=\"iphorm_1_16\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-textarea iphorm_1_35-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-textarea iphorm_1_35-element-spacer\">\n        <label for=\"iphorm_1_35_6acc3aa32c68c\" class=\"iphorm_1_35-outer-label\" >Your hobbies:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-textarea iphorm_1_35-input-wrap\" >\n            <textarea class=\"iphorm-element-textarea  iphorm_1_35\" id=\"iphorm_1_35_6acc3aa32c68c\" name=\"iphorm_1_35\"   rows=\"5\" cols=\"25\"><\/textarea>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_1_18-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_1_18-element-spacer\">\n        <label class=\"iphorm_1_18-outer-label\" >Marital status:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_1_18-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_1_18-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_18-input-li\" >\n                    <label for=\"iphorm_1_18_6acc3aa32c68c_1\"  class=\"iphorm_1_18_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_18 iphorm_1_18_1\" type=\"checkbox\" name=\"iphorm_1_18[]\" id=\"iphorm_1_18_6acc3aa32c68c_1\" value=\"Married\"  \/>\n                        Married                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_18-input-li\" >\n                    <label for=\"iphorm_1_18_6acc3aa32c68c_2\"  class=\"iphorm_1_18_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_18 iphorm_1_18_2\" type=\"checkbox\" name=\"iphorm_1_18[]\" id=\"iphorm_1_18_6acc3aa32c68c_2\" value=\"Single\"  \/>\n                        Single                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_18-input-li\" >\n                    <label for=\"iphorm_1_18_6acc3aa32c68c_3\"  class=\"iphorm_1_18_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_18 iphorm_1_18_3\" type=\"checkbox\" name=\"iphorm_1_18[]\" id=\"iphorm_1_18_6acc3aa32c68c_3\" value=\"Divorced\"  \/>\n                        Divorced                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_18-input-li\" >\n                    <label for=\"iphorm_1_18_6acc3aa32c68c_4\"  class=\"iphorm_1_18_4_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_18 iphorm_1_18_4\" type=\"checkbox\" name=\"iphorm_1_18[]\" id=\"iphorm_1_18_6acc3aa32c68c_4\" value=\"Widow(er)\"  \/>\n                        Widow(er)                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_1_19-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_1_19-element-spacer\">\n        <label class=\"iphorm_1_19-outer-label\" >Children:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_1_19-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_1_19-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_19-input-li\" >\n                    <label for=\"iphorm_1_19_6acc3aa32c68c_1\"  class=\"iphorm_1_19_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_19 iphorm_1_19_1\" type=\"checkbox\" name=\"iphorm_1_19[]\" id=\"iphorm_1_19_6acc3aa32c68c_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_19-input-li\" >\n                    <label for=\"iphorm_1_19_6acc3aa32c68c_2\"  class=\"iphorm_1_19_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_19 iphorm_1_19_2\" type=\"checkbox\" name=\"iphorm_1_19[]\" id=\"iphorm_1_19_6acc3aa32c68c_2\" value=\"None\"  \/>\n                        None                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_1_20-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_1_20-element-spacer\">\n        <label for=\"iphorm_1_20_6acc3aa32c68c\" class=\"iphorm_1_20-outer-label\" >Number of children:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_1_20-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_1_20\" id=\"iphorm_1_20_6acc3aa32c68c\" type=\"text\" name=\"iphorm_1_20\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-textarea iphorm_1_21-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-textarea iphorm_1_21-element-spacer\">\n        <label for=\"iphorm_1_21_6acc3aa32c68c\" class=\"iphorm_1_21-outer-label\" >You can write down the specific issues you are interested in or what specifically the astrologer should take into account when analyzing the Horoscope:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-textarea iphorm_1_21-input-wrap\" >\n            <textarea class=\"iphorm-element-textarea  iphorm_1_21\" id=\"iphorm_1_21_6acc3aa32c68c\" name=\"iphorm_1_21\"   rows=\"5\" cols=\"25\"><\/textarea>\n                <p class=\"iphorm-description\" >The clearer and more specific you formulate the questions and issues you are interested in, the more accurately we will be able to present information to you on the basis of your horoscope.<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_1_22-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_1_22-element-spacer\">\n        <label class=\"iphorm_1_22-outer-label\" >May we contact you should the astrologer have any questions regarding more specific data?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_1_22-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_1_22-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_22-input-li\" >\n                    <label for=\"iphorm_1_22_6acc3aa32c68c_1\"  class=\"iphorm_1_22_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_22 iphorm_1_22_1\" type=\"checkbox\" name=\"iphorm_1_22[]\" id=\"iphorm_1_22_6acc3aa32c68c_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_22-input-li\" >\n                    <label for=\"iphorm_1_22_6acc3aa32c68c_2\"  class=\"iphorm_1_22_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_22 iphorm_1_22_2\" type=\"checkbox\" name=\"iphorm_1_22[]\" id=\"iphorm_1_22_6acc3aa32c68c_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_1_23-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_1_23-element-spacer\">\n        <label for=\"iphorm_1_23_6acc3aa32c68c\" class=\"iphorm_1_23-outer-label\" >Telephone number:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_1_23-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_1_23\" id=\"iphorm_1_23_6acc3aa32c68c\" type=\"text\" name=\"iphorm_1_23\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_1_24-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_1_24-element-spacer\">\n        <label for=\"iphorm_1_24_6acc3aa32c68c\" class=\"iphorm_1_24-outer-label\" >E-mail:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_1_24-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_1_24\" id=\"iphorm_1_24_6acc3aa32c68c\" type=\"text\" name=\"iphorm_1_24\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_1_25-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_1_25-element-spacer\">\n        <label class=\"iphorm_1_25-outer-label\" >Please state in which way you wish to receive the Horoscope you have ordered in a written form:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_1_25-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_1_25-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_25-input-li\" >\n                    <label for=\"iphorm_1_25_6acc3aa32c68c_1\"  class=\"iphorm_1_25_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_25 iphorm_1_25_1\" type=\"checkbox\" name=\"iphorm_1_25[]\" id=\"iphorm_1_25_6acc3aa32c68c_1\" value=\"By e-mail\"  \/>\n                        By e-mail                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_25-input-li\" >\n                    <label for=\"iphorm_1_25_6acc3aa32c68c_2\"  class=\"iphorm_1_25_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_25 iphorm_1_25_2\" type=\"checkbox\" name=\"iphorm_1_25[]\" id=\"iphorm_1_25_6acc3aa32c68c_2\" value=\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"  \/>\n                        By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_1_26-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_1_26-element-spacer\">\n        <label for=\"iphorm_1_26_6acc3aa32c68c\" class=\"iphorm_1_26-outer-label\" >State e-mail address at which you wish to receive the horoscope in a written form:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_1_26-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_1_26\" id=\"iphorm_1_26_6acc3aa32c68c\" type=\"text\" name=\"iphorm_1_26\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-html iphorm_1_28-element-wrap iphorm-clearfix\">\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-html iphorm_1_28-element-spacer\">\n        Please state your exact address at which we could send the Horoscope:    <\/div>\n<\/div>\n<div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_1_27-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_1_27-element-spacer\">\n        <label for=\"iphorm_1_27_6acc3aa32c68c\" class=\"iphorm_1_27-outer-label\" >Country:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_1_27-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_1_27\" id=\"iphorm_1_27_6acc3aa32c68c\" type=\"text\" name=\"iphorm_1_27\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_1_29-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_1_29-element-spacer\">\n        <label for=\"iphorm_1_29_6acc3aa32c68c\" class=\"iphorm_1_29-outer-label\" >City:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_1_29-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_1_29\" id=\"iphorm_1_29_6acc3aa32c68c\" type=\"text\" name=\"iphorm_1_29\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_1_30-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_1_30-element-spacer\">\n        <label for=\"iphorm_1_30_6acc3aa32c68c\" class=\"iphorm_1_30-outer-label\" >Street:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_1_30-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_1_30\" id=\"iphorm_1_30_6acc3aa32c68c\" type=\"text\" name=\"iphorm_1_30\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_1_31-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_1_31-element-spacer\">\n        <label for=\"iphorm_1_31_6acc3aa32c68c\" class=\"iphorm_1_31-outer-label\" >House:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_1_31-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_1_31\" id=\"iphorm_1_31_6acc3aa32c68c\" type=\"text\" name=\"iphorm_1_31\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_1_32-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_1_32-element-spacer\">\n        <label for=\"iphorm_1_32_6acc3aa32c68c\" class=\"iphorm_1_32-outer-label\" >Apartment:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_1_32-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_1_32\" id=\"iphorm_1_32_6acc3aa32c68c\" type=\"text\" name=\"iphorm_1_32\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_1_33-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_1_33-element-spacer\">\n        <label class=\"iphorm_1_33-outer-label\" >Order confirmation:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_1_33-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_1_33-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_1_33-input-li\" >\n                    <label for=\"iphorm_1_33_6acc3aa32c68c_1\"  class=\"iphorm_1_33_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_1_33 iphorm_1_33_1\" type=\"checkbox\" name=\"iphorm_1_33[]\" id=\"iphorm_1_33_6acc3aa32c68c_1\" value=\"I order a horoscope and guarantee that the data presented in the registration form is true. \"  \/>\n                        I order a horoscope and guarantee that the data presented in the registration form is true.                     <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-recaptcha g-recaptcha-response-element-wrap iphorm_1_40-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-required\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-captcha g-recaptcha-response-element-spacer\">\n        <label class=\"g-recaptcha-response-outer-label\" >Are you human?<span class=\"iphorm-required\">(required)<\/span><\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-recaptcha g-recaptcha-response-input-wrap\" >\n                            <div id=\"iphorm_1_40_6acc3aa32c68c\" class=\"iphorm-recaptcha\" data-unique-id=\"iphorm_1_40_6acc3aa32c68c\" data-config=\"{&quot;sitekey&quot;:&quot;6LedJT8UAAAAAF98QMjpclkDUi0x8zoTC2M7u2VB&quot;,&quot;theme&quot;:&quot;light&quot;,&quot;type&quot;:&quot;image&quot;,&quot;size&quot;:&quot;normal&quot;}\"><\/div>\n                <noscript>\n                  <div style=\"width: 302px; height: 352px;\">\n                    <div style=\"width: 302px; height: 352px; position: relative;\">\n                      <div style=\"width: 302px; height: 352px; position: absolute;\">\n                        <iframe src=\"https:\/\/www.google.com\/recaptcha\/api\/fallback?k=6LedJT8UAAAAAF98QMjpclkDUi0x8zoTC2M7u2VB\"\n                                frameborder=\"0\" scrolling=\"no\"\n                                style=\"width: 302px; height:352px; border-style: none;\">\n                        <\/iframe>\n                      <\/div>\n                      <div style=\"width: 250px; height: 80px; position: absolute; border-style: none;\n                                  bottom: 21px; left: 25px; margin: 0px; padding: 0px; right: 25px;\">\n                        <textarea name=\"g-recaptcha-response\" class=\"g-recaptcha-response\"\n                                  style=\"width: 250px; height: 80px; border: 1px solid #c1c1c1;\n                                         margin: 0px; padding: 0px; resize: none;\"><\/textarea>\n                      <\/div>\n                    <\/div>\n                  <\/div>\n                <\/noscript>\n                                <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-hidden\">\n    <label>This field should be left blank<input type=\"text\" name=\"iphorm_1_0\" \/><\/label>\n<\/div>                <div class=\"iphorm-submit-wrap iphorm-submit-wrap-1 iphorm-clearfix\" >\n                    <div class=\"iphorm-submit-input-wrap iphorm-submit-input-wrap-1\" >\n                        <button class=\"iphorm-submit-element\" type=\"submit\" name=\"iphorm_submit\" ><span ><em >ORDER<\/em><\/span><\/button>\n                    <\/div>\n                    <div class=\"iphorm-loading-wrap\"><span class=\"iphorm-loading\">Please wait...<\/span><\/div>\n                <\/div>\n            <\/div>\n                                                                        <div class=\"iphorm-success-message iphorm-hidden\" ><\/div>\n                                    <\/div>\n            <\/form>\n    <script type=\"text\/javascript\">\n    jQuery('#iphorm-outer-6acc3aa32c68c script').remove();\n    <\/script>\n<\/div>\t<\/div>\r\n\r\n\t<div class=\"hidden-form form-AP\">\r\n\t<div id=\"iphorm-outer-6acc3aa32fb41\" class=\"iphorm-outer iphorm-outer-2 iphorm-uniform-theme-default iphorm-theme-light-light iphorm-has-logic\" >\n    <script type=\"text\/javascript\">\n        jQuery(document).ready(function($) {\n                            iPhorm.logic[2] = {\"logic\":{\"14\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"13\",\"operator\":\"eq\",\"value\":\"Secondary-special\"},{\"element_id\":\"13\",\"operator\":\"eq\",\"value\":\"Higher\"}]},\"16\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"15\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"20\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"19\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"36\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"35\",\"operator\":\"eq\",\"value\":\"For a month\"}]},\"23\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"22\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"24\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"22\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"26\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By e-mail\"}]},\"28\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"27\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"29\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"30\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"31\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"32\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]}},\"dependents\":{\"13\":[14,14],\"15\":[16],\"19\":[20],\"35\":[36],\"22\":[23,24],\"25\":[26,28,27,29,30,31,32]},\"animate\":true};\n                        $('#iphorm-6acc3aa32fb41').iPhorm({\"id\":2,\"uniqueId\":\"6acc3aa32fb41\",\"useAjax\":true,\"successMessageTimeout\":160,\"resetFormValues\":\"\",\"clElementIds\":[14,16,20,36,23,24,26,28,27,29,30,31,32],\"clDependentElementIds\":[13,15,19,35,22,25],\"centerFancybox\":true,\"centerFancyboxSpeed\":true});\n                        if ($.isFunction($.fn.qtip)) {\n                $('.iphorm-tooltip-hover', iPhorm.instance.$form).qtip({\n                    style: {\n                        classes: 'qtip-plain qtip-shadow'\n                    },\n                    position: {\n                        my: 'left center',\n                        at: 'right center',\n                        viewport: $(window),\n                        adjust: {\n                            method: 'shift'\n                        }\n                    }\n                });\n                $('.iphorm-tooltip-click', iPhorm.instance.$form).qtip({\n                    style: {\n                        classes: 'qtip-plain qtip-shadow'\n                    },\n                    position: {\n                        my: 'left center',\n                        at: 'right center',\n                        viewport: $(window),\n                        adjust: {\n                            method: 'shift'\n                        }\n                    },\n                    show: {\n                        event: 'focus'\n                    },\n                    hide: {\n                        event: 'unfocus'\n                    }\n                });\n                $('.iphorm-tooltip-icon-hover', iPhorm.instance.$form).qtip({\n                    style: {\n                        classes: 'qtip-plain qtip-shadow'\n                    },\n                    position: {\n                        my: 'left center',\n                        at: 'right center',\n                        viewport: $(window),\n                        adjust: {\n                            method: 'shift'\n                        }\n                    },\n                    content: {\n                        text: function (api) {\n                            return $(this).find('.iphorm-tooltip-icon-content').html();\n                        }\n                    }\n                });\n                $('.iphorm-tooltip-icon-click', iPhorm.instance.$form).qtip({\n                    style: {\n                        classes: 'qtip-plain qtip-shadow'\n                    },\n                    position: {\n                        my: 'left center',\n                        at: 'right center',\n                        viewport: $(window),\n                        adjust: {\n                            method: 'shift'\n                        }\n                    },\n                    show: {\n                        event: 'click'\n                    },\n                    hide: {\n                        event: 'unfocus'\n                    },\n                    content: {\n                        text: function (api) {\n                            return $(this).find('.iphorm-tooltip-icon-content').html();\n                        }\n                    }\n                });\n                $('.iphorm-labels-inside > .iphorm-element-spacer > label').hover(function () {\n                    $(this).siblings('.iphorm-input-wrap').find('.iphorm-tooltip-hover').qtip('show');\n                }, function () {\n                    $(this).siblings('.iphorm-input-wrap').find('.iphorm-tooltip-hover').qtip('hide');\n                });\n            }\n                                    if ($.isFunction($.fn.uniform)) {\n                $('select, input:checkbox, input:radio', iPhorm.instance.$form).uniform({context: iPhorm.instance.$form, selectAutoWidth: false});\n            }\n                        if ($.isFunction($.fn.inFieldLabels)) {\n                $('.iphorm-labels-inside:not(.iphorm-element-wrap-recaptcha) > .iphorm-element-spacer > label', iPhorm.instance.$form).inFieldLabels();\n            }\n                        $('.iphorm-group-row > div:last-child:not(:first-child)', iPhorm.instance.$form).add('.iphorm-group-row:last-child', iPhorm.instance.$form).addClass('last-child');\n                            iPhorm.instance.applyAllLogic(true);\n                $('#iphorm-outer-6acc3aa32fb41').css('visibility', 'visible');\n                    });\n    <\/script>\n    <form id=\"iphorm-6acc3aa32fb41\" class=\"iphorm iphorm-form-2\" action=\"\/en\/wp-json\/wp\/v2\/pages\/40#iphorm-6acc3aa32fb41\" method=\"post\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\">\n        <div class=\"iphorm-inner iphorm-inner-2\" >\n            <input type=\"hidden\" name=\"iphorm_id\" value=\"2\" \/>\n            <input type=\"hidden\" name=\"iphorm_uid\" value=\"6acc3aa32fb41\" \/>\n            <input type=\"hidden\" name=\"form_url\" value=\"http:\/\/www.e-astrology.eu\/en\/wp-json\/wp\/v2\/pages\/40\" \/>\n            <input type=\"hidden\" name=\"referring_url\" value=\"\" \/>\n            <input type=\"hidden\" name=\"post_id\" value=\"\" \/>\n            <input type=\"hidden\" name=\"post_title\" value=\"\" \/>\n                            <h3 class=\"iphorm-title\" >ASTROLOGICAL PREDICTION \u2013 ORDER FORM<\/h3>\n                                                <div class=\"iphorm-elements iphorm-elements-2 iphorm-clearfix\" >\n                Attention! Please complete all boxes of the questionnaire very carefully. The Centre guarantees that all information stated in the registration form and information concerning your horoscope is confidential and it shall not be disclosed to any third parties in any case.\n<br><\/br><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_2_39-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_2_39-element-spacer\">\n        <label class=\"iphorm_2_39-outer-label\" >Type (kind) of ORAL consultation:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_2_39-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_2_39-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_39-input-li\" >\n                    <label for=\"iphorm_2_39_6acc3aa32fb41_1\"  class=\"iphorm_2_39_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_39 iphorm_2_39_1\" type=\"checkbox\" name=\"iphorm_2_39[]\" id=\"iphorm_2_39_6acc3aa32fb41_1\" value=\"Consultation on SKYPE (cost 50 eur)\"  \/>\n                        Consultation on SKYPE (cost 50 eur)                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_39-input-li\" >\n                    <label for=\"iphorm_2_39_6acc3aa32fb41_2\"  class=\"iphorm_2_39_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_39 iphorm_2_39_2\" type=\"checkbox\" name=\"iphorm_2_39[]\" id=\"iphorm_2_39_6acc3aa32fb41_2\" value=\"Personal visit\/meeting (only in Vilnius, Lithuania)\"  \/>\n                        Personal visit\/meeting (only in Vilnius, Lithuania)                    <\/label>\n                <\/div>\n                        <\/div>\n                <p class=\"iphorm-description\" >Attention! The cost of personal consultation (meeting with the astrologer) is determined individually.<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_2_40-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_2_40-element-spacer\">\n        <label class=\"iphorm_2_40-outer-label\" >Order of the Horoscope in a written form:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_2_40-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_2_40-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_40-input-li\" >\n                    <label for=\"iphorm_2_40_6acc3aa32fb41_1\"  class=\"iphorm_2_40_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_40 iphorm_2_40_1\" type=\"checkbox\" name=\"iphorm_2_40[]\" id=\"iphorm_2_40_6acc3aa32fb41_1\" value=\"I want to order the Horoscope in a WRITTEN form\"  \/>\n                        I want to order the Horoscope in a WRITTEN form                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_2_34-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_2_34-element-spacer\">\n        <label class=\"iphorm_2_34-outer-label\" >I want to order the horoscope:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_2_34-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_2_34-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_34-input-li\" >\n                    <label for=\"iphorm_2_34_6acc3aa32fb41_1\"  class=\"iphorm_2_34_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_34 iphorm_2_34_1\" type=\"checkbox\" name=\"iphorm_2_34[]\" id=\"iphorm_2_34_6acc3aa32fb41_1\" value=\"in English Language \u2013 120 eur\"  \/>\n                        in English Language \u2013 120 eur                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_34-input-li\" >\n                    <label for=\"iphorm_2_34_6acc3aa32fb41_2\"  class=\"iphorm_2_34_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_34 iphorm_2_34_2\" type=\"checkbox\" name=\"iphorm_2_34[]\" id=\"iphorm_2_34_6acc3aa32fb41_2\" value=\"in Russian Language \u2013 60 eur\"  \/>\n                        in Russian Language \u2013 60 eur                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_34-input-li\" >\n                    <label for=\"iphorm_2_34_6acc3aa32fb41_3\"  class=\"iphorm_2_34_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_34 iphorm_2_34_3\" type=\"checkbox\" name=\"iphorm_2_34[]\" id=\"iphorm_2_34_6acc3aa32fb41_3\" value=\"in Lithuanian Language \u2013 120 eur\"  \/>\n                        in Lithuanian Language \u2013 120 eur                    <\/label>\n                <\/div>\n                        <\/div>\n                <p class=\"iphorm-description\" >The cost of a written horoscope depends on the chosen language<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_2_2-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_2_2-element-spacer\">\n        <label for=\"iphorm_2_2_6acc3aa32fb41\" class=\"iphorm_2_2-outer-label\" >Name and surname:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_2_2-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_2_2\" id=\"iphorm_2_2_6acc3aa32fb41\" type=\"text\" name=\"iphorm_2_2\"  value=\"\"  \/>\n                <p class=\"iphorm-description\" >* We need your name and surname to check and receive the bank transfer (payment of your order).<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_2_3-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_2_3-element-spacer\">\n        <label class=\"iphorm_2_3-outer-label\" >Sex:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_2_3-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_2_3-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_3-input-li\" >\n                    <label for=\"iphorm_2_3_6acc3aa32fb41_1\"  class=\"iphorm_2_3_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_3 iphorm_2_3_1\" type=\"checkbox\" name=\"iphorm_2_3[]\" id=\"iphorm_2_3_6acc3aa32fb41_1\" value=\"Male\"  \/>\n                        Male                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_3-input-li\" >\n                    <label for=\"iphorm_2_3_6acc3aa32fb41_2\"  class=\"iphorm_2_3_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_3 iphorm_2_3_2\" type=\"checkbox\" name=\"iphorm_2_3[]\" id=\"iphorm_2_3_6acc3aa32fb41_2\" value=\"Female\"  \/>\n                        Female                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-date iphorm_2_4-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\r\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-date iphorm_2_4-element-spacer\">\r\n        <label id=\"iphorm_2_4_6acc3aa32fb41_date_label\" class=\"iphorm_2_4-outer-label\" >Date of birth:<\/label>        <div id=\"iphorm_2_4_6acc3aa32fb41\" class=\"iphorm-input-wrap iphorm-input-wrap-date iphorm_2_4-input-wrap\" >\r\n        \t<div class=\"iphorm-clearfix\">\r\n                <div class=\"iphorm-input-wrap-date-select-wrap\">\r\n                                                                                <label id=\"iphorm_2_4_6acc3aa32fb41_day_label\" class=\"iphorm-screen-reader-text\">Day<\/label>\r\n                    <select id=\"iphorm_2_4_6acc3aa32fb41_day\" name=\"iphorm_2_4[day]\" class=\"iphorm_2_4-input-day\" aria-labelledby=\"iphorm_2_4_6acc3aa32fb41_date_label iphorm_2_4_6acc3aa32fb41_day_label\" >\r\n                        <option value=\"\">Day<\/option>                                                    <option value=\"1\" >1<\/option>\r\n                                                    <option value=\"2\" >2<\/option>\r\n                                                    <option value=\"3\" >3<\/option>\r\n                                                    <option value=\"4\" >4<\/option>\r\n                                                    <option value=\"5\" >5<\/option>\r\n                                                    <option value=\"6\" >6<\/option>\r\n                                                    <option value=\"7\" >7<\/option>\r\n                                                    <option value=\"8\" >8<\/option>\r\n                                                    <option value=\"9\" >9<\/option>\r\n                                                    <option value=\"10\" >10<\/option>\r\n                                                    <option value=\"11\" >11<\/option>\r\n                                                    <option value=\"12\" >12<\/option>\r\n                                                    <option value=\"13\" >13<\/option>\r\n                                                    <option value=\"14\" >14<\/option>\r\n                                                    <option value=\"15\" >15<\/option>\r\n                                                    <option value=\"16\" >16<\/option>\r\n                                                    <option value=\"17\" >17<\/option>\r\n                                                    <option value=\"18\" >18<\/option>\r\n                                                    <option value=\"19\" >19<\/option>\r\n                                                    <option value=\"20\" >20<\/option>\r\n                                                    <option value=\"21\" >21<\/option>\r\n                                                    <option value=\"22\" >22<\/option>\r\n                                                    <option value=\"23\" >23<\/option>\r\n                                                    <option value=\"24\" >24<\/option>\r\n                                                    <option value=\"25\" >25<\/option>\r\n                                                    <option value=\"26\" >26<\/option>\r\n                                                    <option value=\"27\" >27<\/option>\r\n                                                    <option value=\"28\" >28<\/option>\r\n                                                    <option value=\"29\" >29<\/option>\r\n                                                    <option value=\"30\" >30<\/option>\r\n                                                    <option value=\"31\" >31<\/option>\r\n                                            <\/select>\r\n                                        <label id=\"iphorm_2_4_6acc3aa32fb41_month_label\" class=\"iphorm-screen-reader-text\">Month<\/label>\r\n                    <select id=\"iphorm_2_4_6acc3aa32fb41_month\" name=\"iphorm_2_4[month]\" class=\"iphorm_2_4-input-month\" aria-labelledby=\"iphorm_2_4_6acc3aa32fb41_date_label iphorm_2_4_6acc3aa32fb41_month_label\" >\r\n                        <option value=\"\">Month<\/option>                                                    <option value=\"1\" >1<\/option>\r\n                                                    <option value=\"2\" >2<\/option>\r\n                                                    <option value=\"3\" >3<\/option>\r\n                                                    <option value=\"4\" >4<\/option>\r\n                                                    <option value=\"5\" >5<\/option>\r\n                                                    <option value=\"6\" >6<\/option>\r\n                                                    <option value=\"7\" >7<\/option>\r\n                                                    <option value=\"8\" >8<\/option>\r\n                                                    <option value=\"9\" >9<\/option>\r\n                                                    <option value=\"10\" >10<\/option>\r\n                                                    <option value=\"11\" >11<\/option>\r\n                                                    <option value=\"12\" >12<\/option>\r\n                                            <\/select>\r\n                                        <label id=\"iphorm_2_4_6acc3aa32fb41_year_label\" class=\"iphorm-screen-reader-text\">Year<\/label>\r\n                    <select id=\"iphorm_2_4_6acc3aa32fb41_year\" name=\"iphorm_2_4[year]\" class=\"iphorm_2_4-input-year\" aria-labelledby=\"iphorm_2_4_6acc3aa32fb41_date_label iphorm_2_4_6acc3aa32fb41_year_label\" >\r\n                        <option value=\"\">Year<\/option>                                                                                    <option value=\"2030\" >2030<\/option>\r\n                                                            <option value=\"2029\" >2029<\/option>\r\n                                                            <option value=\"2028\" >2028<\/option>\r\n                                                            <option value=\"2027\" >2027<\/option>\r\n                                                            <option value=\"2026\" >2026<\/option>\r\n                                                            <option value=\"2025\" >2025<\/option>\r\n                                                            <option value=\"2024\" >2024<\/option>\r\n                                                            <option value=\"2023\" >2023<\/option>\r\n                                                            <option value=\"2022\" >2022<\/option>\r\n                                                            <option value=\"2021\" >2021<\/option>\r\n                                                            <option value=\"2020\" >2020<\/option>\r\n                                                            <option value=\"2019\" >2019<\/option>\r\n                                                            <option value=\"2018\" >2018<\/option>\r\n                                                            <option value=\"2017\" >2017<\/option>\r\n                                                            <option value=\"2016\" >2016<\/option>\r\n                                                            <option value=\"2015\" >2015<\/option>\r\n                                                            <option value=\"2014\" >2014<\/option>\r\n                                                            <option value=\"2013\" >2013<\/option>\r\n                                                            <option value=\"2012\" >2012<\/option>\r\n                                                            <option value=\"2011\" >2011<\/option>\r\n                                                            <option value=\"2010\" >2010<\/option>\r\n                                                            <option value=\"2009\" >2009<\/option>\r\n                                                            <option value=\"2008\" >2008<\/option>\r\n                                                            <option value=\"2007\" >2007<\/option>\r\n                                                            <option value=\"2006\" >2006<\/option>\r\n                                                            <option value=\"2005\" >2005<\/option>\r\n                                                            <option value=\"2004\" >2004<\/option>\r\n                                                            <option value=\"2003\" >2003<\/option>\r\n                                                            <option value=\"2002\" >2002<\/option>\r\n                                                            <option value=\"2001\" >2001<\/option>\r\n                                                            <option value=\"2000\" >2000<\/option>\r\n                                                            <option value=\"1999\" >1999<\/option>\r\n                                                            <option value=\"1998\" >1998<\/option>\r\n                                                            <option value=\"1997\" >1997<\/option>\r\n                                                            <option value=\"1996\" >1996<\/option>\r\n                                                            <option value=\"1995\" >1995<\/option>\r\n                                                            <option value=\"1994\" >1994<\/option>\r\n                                                            <option value=\"1993\" >1993<\/option>\r\n                                                            <option value=\"1992\" >1992<\/option>\r\n                                                            <option value=\"1991\" >1991<\/option>\r\n                                                            <option value=\"1990\" >1990<\/option>\r\n                                                            <option value=\"1989\" >1989<\/option>\r\n                                                            <option value=\"1988\" >1988<\/option>\r\n                                                            <option value=\"1987\" >1987<\/option>\r\n                                                            <option value=\"1986\" >1986<\/option>\r\n                                                            <option value=\"1985\" >1985<\/option>\r\n                                                            <option value=\"1984\" >1984<\/option>\r\n                                                            <option value=\"1983\" >1983<\/option>\r\n                                                            <option value=\"1982\" >1982<\/option>\r\n                                                            <option value=\"1981\" >1981<\/option>\r\n                                                            <option value=\"1980\" >1980<\/option>\r\n                                                            <option value=\"1979\" >1979<\/option>\r\n                                                            <option value=\"1978\" >1978<\/option>\r\n                                                            <option value=\"1977\" >1977<\/option>\r\n                                                            <option value=\"1976\" >1976<\/option>\r\n                                                            <option value=\"1975\" >1975<\/option>\r\n                                                            <option value=\"1974\" >1974<\/option>\r\n                                                            <option value=\"1973\" >1973<\/option>\r\n                                                            <option value=\"1972\" >1972<\/option>\r\n                                                            <option value=\"1971\" >1971<\/option>\r\n                                                            <option value=\"1970\" >1970<\/option>\r\n                                                            <option value=\"1969\" >1969<\/option>\r\n                                                            <option value=\"1968\" >1968<\/option>\r\n                                                            <option value=\"1967\" >1967<\/option>\r\n                                                            <option value=\"1966\" >1966<\/option>\r\n                                                            <option value=\"1965\" >1965<\/option>\r\n                                                            <option value=\"1964\" >1964<\/option>\r\n                                                            <option value=\"1963\" >1963<\/option>\r\n                                                            <option value=\"1962\" >1962<\/option>\r\n                                                            <option value=\"1961\" >1961<\/option>\r\n                                                            <option value=\"1960\" >1960<\/option>\r\n                                                            <option value=\"1959\" >1959<\/option>\r\n                                                            <option value=\"1958\" >1958<\/option>\r\n                                                            <option value=\"1957\" >1957<\/option>\r\n                                                            <option value=\"1956\" >1956<\/option>\r\n                                                            <option value=\"1955\" >1955<\/option>\r\n                                                            <option value=\"1954\" >1954<\/option>\r\n                                                            <option value=\"1953\" >1953<\/option>\r\n                                                            <option value=\"1952\" >1952<\/option>\r\n                                                            <option value=\"1951\" >1951<\/option>\r\n                                                            <option value=\"1950\" >1950<\/option>\r\n                                                            <option value=\"1949\" >1949<\/option>\r\n                                                            <option value=\"1948\" >1948<\/option>\r\n                                                            <option value=\"1947\" >1947<\/option>\r\n                                                            <option value=\"1946\" >1946<\/option>\r\n                                                            <option value=\"1945\" >1945<\/option>\r\n                                                            <option value=\"1944\" >1944<\/option>\r\n                                                            <option value=\"1943\" >1943<\/option>\r\n                                                            <option value=\"1942\" >1942<\/option>\r\n                                                            <option value=\"1941\" >1941<\/option>\r\n                                                            <option value=\"1940\" >1940<\/option>\r\n                                                            <option value=\"1939\" >1939<\/option>\r\n                                                            <option value=\"1938\" >1938<\/option>\r\n                                                            <option value=\"1937\" >1937<\/option>\r\n                                                            <option value=\"1936\" >1936<\/option>\r\n                                                            <option value=\"1935\" >1935<\/option>\r\n                                                            <option value=\"1934\" >1934<\/option>\r\n                                                            <option value=\"1933\" >1933<\/option>\r\n                                                            <option value=\"1932\" >1932<\/option>\r\n                                                            <option value=\"1931\" >1931<\/option>\r\n                                                            <option value=\"1930\" >1930<\/option>\r\n                                                            <option value=\"1929\" >1929<\/option>\r\n                                                            <option value=\"1928\" >1928<\/option>\r\n                                                            <option value=\"1927\" >1927<\/option>\r\n                                                            <option value=\"1926\" >1926<\/option>\r\n                                                            <option value=\"1925\" >1925<\/option>\r\n                                                            <option value=\"1924\" >1924<\/option>\r\n                                                            <option value=\"1923\" >1923<\/option>\r\n                                                            <option value=\"1922\" >1922<\/option>\r\n                                                            <option value=\"1921\" >1921<\/option>\r\n                                                            <option value=\"1920\" >1920<\/option>\r\n                                                            <option value=\"1919\" >1919<\/option>\r\n                                                            <option value=\"1918\" >1918<\/option>\r\n                                                            <option value=\"1917\" >1917<\/option>\r\n                                                            <option value=\"1916\" >1916<\/option>\r\n                                                            <option value=\"1915\" >1915<\/option>\r\n                                                            <option value=\"1914\" >1914<\/option>\r\n                                                            <option value=\"1913\" >1913<\/option>\r\n                                                            <option value=\"1912\" >1912<\/option>\r\n                                                            <option value=\"1911\" >1911<\/option>\r\n                                                            <option value=\"1910\" >1910<\/option>\r\n                                                            <option value=\"1909\" >1909<\/option>\r\n                                                            <option value=\"1908\" >1908<\/option>\r\n                                                            <option value=\"1907\" >1907<\/option>\r\n                                                            <option value=\"1906\" >1906<\/option>\r\n                                                            <option value=\"1905\" >1905<\/option>\r\n                                                            <option value=\"1904\" >1904<\/option>\r\n                                                            <option value=\"1903\" >1903<\/option>\r\n                                                            <option value=\"1902\" >1902<\/option>\r\n                                                            <option value=\"1901\" >1901<\/option>\r\n                                                            <option value=\"1900\" >1900<\/option>\r\n                                                                        <\/select>\r\n                <\/div>\r\n                            <\/div>\r\n                    <\/div>\r\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\r\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-time iphorm_2_5-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-time iphorm_2_5-element-spacer\">\n        <label id=\"iphorm_2_5_6acc3aa32fb41_time_label\" class=\"iphorm_2_5-outer-label\" >Exact time of birth (hours and minutes):<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-date iphorm_2_5-input-wrap\" >\n            <label id=\"iphorm_2_5_6acc3aa32fb41_hour_label\" class=\"iphorm-screen-reader-text\">Hour<\/label>\n            <select id=\"iphorm_2_5_6acc3aa32fb41_hour\"  name=\"iphorm_2_5[hour]\" class=\"iphorm_2_5-input-hour\" aria-labelledby=\"iphorm_2_5_6acc3aa32fb41_time_label iphorm_2_5_6acc3aa32fb41_hour_label\" >\n                <option value=\"\">HH<\/option>                                                                                    <option value=\"00\" >00<\/option>\n                                                                    <option value=\"01\" >01<\/option>\n                                                                    <option value=\"02\" >02<\/option>\n                                                                    <option value=\"03\" >03<\/option>\n                                                                    <option value=\"04\" >04<\/option>\n                                                                    <option value=\"05\" >05<\/option>\n                                                                    <option value=\"06\" >06<\/option>\n                                                                    <option value=\"07\" >07<\/option>\n                                                                    <option value=\"08\" >08<\/option>\n                                                                    <option value=\"09\" >09<\/option>\n                                                                    <option value=\"10\" >10<\/option>\n                                                                    <option value=\"11\" >11<\/option>\n                                                                    <option value=\"12\"  selected='selected'>12<\/option>\n                                                                    <option value=\"13\" >13<\/option>\n                                                                    <option value=\"14\" >14<\/option>\n                                                                    <option value=\"15\" >15<\/option>\n                                                                    <option value=\"16\" >16<\/option>\n                                                                    <option value=\"17\" >17<\/option>\n                                                                    <option value=\"18\" >18<\/option>\n                                                                    <option value=\"19\" >19<\/option>\n                                                                    <option value=\"20\" >20<\/option>\n                                                                    <option value=\"21\" >21<\/option>\n                                                                    <option value=\"22\" >22<\/option>\n                                                                    <option value=\"23\" >23<\/option>\n                                                <\/select>\n            <label id=\"iphorm_2_5_6acc3aa32fb41_minute_label\" class=\"iphorm-screen-reader-text\">Minute<\/label>\n            <select id=\"iphorm_2_5_6acc3aa32fb41_minute\" name=\"iphorm_2_5[minute]\" class=\"iphorm_2_5-input-minute\" aria-labelledby=\"iphorm_2_5_6acc3aa32fb41_time_label iphorm_2_5_6acc3aa32fb41_minute_label\" >\n                <option value=\"\">MM<\/option>                                                                                    <option value=\"00\"  selected='selected'>00<\/option>\n                                                                                                        <option value=\"01\" >01<\/option>\n                                                                                                        <option value=\"02\" >02<\/option>\n                                                                                                        <option value=\"03\" >03<\/option>\n                                                                                                        <option value=\"04\" >04<\/option>\n                                                                                                        <option value=\"05\" >05<\/option>\n                                                                                                        <option value=\"06\" >06<\/option>\n                                                                                                        <option value=\"07\" >07<\/option>\n                                                                                                        <option value=\"08\" >08<\/option>\n                                                                                                        <option value=\"09\" >09<\/option>\n                                                                                                        <option value=\"10\" >10<\/option>\n                                                                                                        <option value=\"11\" >11<\/option>\n                                                                                                        <option value=\"12\" >12<\/option>\n                                                                                                        <option value=\"13\" >13<\/option>\n                                                                                                        <option value=\"14\" >14<\/option>\n                                                                                                        <option value=\"15\" >15<\/option>\n                                                                                                        <option value=\"16\" >16<\/option>\n                                                                                                        <option value=\"17\" >17<\/option>\n                                                                                                        <option value=\"18\" >18<\/option>\n                                                                                                        <option value=\"19\" >19<\/option>\n                                                                                                        <option value=\"20\" >20<\/option>\n                                                                                                        <option value=\"21\" >21<\/option>\n                                                                                                        <option value=\"22\" >22<\/option>\n                                                                                                        <option value=\"23\" >23<\/option>\n                                                                                                        <option value=\"24\" >24<\/option>\n                                                                                                        <option value=\"25\" >25<\/option>\n                                                                                                        <option value=\"26\" >26<\/option>\n                                                                                                        <option value=\"27\" >27<\/option>\n                                                                                                        <option value=\"28\" >28<\/option>\n                                                                                                        <option value=\"29\" >29<\/option>\n                                                                                                        <option value=\"30\" >30<\/option>\n                                                                                                        <option value=\"31\" >31<\/option>\n                                                                                                        <option value=\"32\" >32<\/option>\n                                                                                                        <option value=\"33\" >33<\/option>\n                                                                                                        <option value=\"34\" >34<\/option>\n                                                                                                        <option value=\"35\" >35<\/option>\n                                                                                                        <option value=\"36\" >36<\/option>\n                                                                                                        <option value=\"37\" >37<\/option>\n                                                                                                        <option value=\"38\" >38<\/option>\n                                                                                                        <option value=\"39\" >39<\/option>\n                                                                                                        <option value=\"40\" >40<\/option>\n                                                                                                        <option value=\"41\" >41<\/option>\n                                                                                                        <option value=\"42\" >42<\/option>\n                                                                                                        <option value=\"43\" >43<\/option>\n                                                                                                        <option value=\"44\" >44<\/option>\n                                                                                                        <option value=\"45\" >45<\/option>\n                                                                                                        <option value=\"46\" >46<\/option>\n                                                                                                        <option value=\"47\" >47<\/option>\n                                                                                                        <option value=\"48\" >48<\/option>\n                                                                                                        <option value=\"49\" >49<\/option>\n                                                                                                        <option value=\"50\" >50<\/option>\n                                                                                                        <option value=\"51\" >51<\/option>\n                                                                                                        <option value=\"52\" >52<\/option>\n                                                                                                        <option value=\"53\" >53<\/option>\n                                                                                                        <option value=\"54\" >54<\/option>\n                                                                                                        <option value=\"55\" >55<\/option>\n                                                                                                        <option value=\"56\" >56<\/option>\n                                                                                                        <option value=\"57\" >57<\/option>\n                                                                                                        <option value=\"58\" >58<\/option>\n                                                                                                        <option value=\"59\" >59<\/option>\n                                                <\/select>\n                            <input type=\"hidden\" name=\"iphorm_2_5[ampm]\" value=\"\" \/>\n                                <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_2_6-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_2_6-element-spacer\">\n        <label class=\"iphorm_2_6-outer-label\" >If you don\u2019t know the exact time of birth, enter the approximate time and tick this box:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_2_6-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_2_6-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_6-input-li\" >\n                    <label for=\"iphorm_2_6_6acc3aa32fb41_1\"  class=\"iphorm_2_6_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_6 iphorm_2_6_1\" type=\"checkbox\" name=\"iphorm_2_6[]\" id=\"iphorm_2_6_6acc3aa32fb41_1\" value=\"I know the approximate time of birth only.\"  \/>\n                        I know the approximate time of birth only.                    <\/label>\n                <\/div>\n                        <\/div>\n                <p class=\"iphorm-description\" >Attention! If you don\u2019t know the exact time of birth, predictions may be inaccurate. The approximate time of birth can be stated for psychological and compatibility horoscopes. The more exact time of birth is stated, the more accurate the prediction is!<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_2_9-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_2_9-element-spacer\">\n        <label for=\"iphorm_2_9_6acc3aa32fb41\" class=\"iphorm_2_9-outer-label\" >Exact country of birth:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_2_9-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_2_9\" id=\"iphorm_2_9_6acc3aa32fb41\" type=\"text\" name=\"iphorm_2_9\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_2_10-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_2_10-element-spacer\">\n        <label for=\"iphorm_2_10_6acc3aa32fb41\" class=\"iphorm_2_10-outer-label\" >Exact city of birth:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_2_10-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_2_10\" id=\"iphorm_2_10_6acc3aa32fb41\" type=\"text\" name=\"iphorm_2_10\"  value=\"\"  \/>\n                <p class=\"iphorm-description\" >(If you were born in a small settlement, state the closest city.)<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_2_11-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_2_11-element-spacer\">\n        <label for=\"iphorm_2_11_6acc3aa32fb41\" class=\"iphorm_2_11-outer-label\" >Country where you live in now:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_2_11-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_2_11\" id=\"iphorm_2_11_6acc3aa32fb41\" type=\"text\" name=\"iphorm_2_11\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_2_12-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_2_12-element-spacer\">\n        <label for=\"iphorm_2_12_6acc3aa32fb41\" class=\"iphorm_2_12-outer-label\" >City where you live in now:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_2_12-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_2_12\" id=\"iphorm_2_12_6acc3aa32fb41\" type=\"text\" name=\"iphorm_2_12\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_2_13-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_2_13-element-spacer\">\n        <label class=\"iphorm_2_13-outer-label\" >Your education:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_2_13-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_2_13-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_13-input-li\" >\n                    <label for=\"iphorm_2_13_6acc3aa32fb41_1\"  class=\"iphorm_2_13_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_13 iphorm_2_13_1\" type=\"checkbox\" name=\"iphorm_2_13[]\" id=\"iphorm_2_13_6acc3aa32fb41_1\" value=\"Secondary\"  \/>\n                        Secondary                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_13-input-li\" >\n                    <label for=\"iphorm_2_13_6acc3aa32fb41_2\"  class=\"iphorm_2_13_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_13 iphorm_2_13_2\" type=\"checkbox\" name=\"iphorm_2_13[]\" id=\"iphorm_2_13_6acc3aa32fb41_2\" value=\"Secondary-special\"  \/>\n                        Secondary-special                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_13-input-li\" >\n                    <label for=\"iphorm_2_13_6acc3aa32fb41_3\"  class=\"iphorm_2_13_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_13 iphorm_2_13_3\" type=\"checkbox\" name=\"iphorm_2_13[]\" id=\"iphorm_2_13_6acc3aa32fb41_3\" value=\"Higher\"  \/>\n                        Higher                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_2_14-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_2_14-element-spacer\">\n        <label for=\"iphorm_2_14_6acc3aa32fb41\" class=\"iphorm_2_14-outer-label\" >State the speciality:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_2_14-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_2_14\" id=\"iphorm_2_14_6acc3aa32fb41\" type=\"text\" name=\"iphorm_2_14\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_2_15-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_2_15-element-spacer\">\n        <label class=\"iphorm_2_15-outer-label\" >Are you employed at the moment?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_2_15-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_2_15-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_15-input-li\" >\n                    <label for=\"iphorm_2_15_6acc3aa32fb41_1\"  class=\"iphorm_2_15_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_15 iphorm_2_15_1\" type=\"checkbox\" name=\"iphorm_2_15[]\" id=\"iphorm_2_15_6acc3aa32fb41_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_15-input-li\" >\n                    <label for=\"iphorm_2_15_6acc3aa32fb41_2\"  class=\"iphorm_2_15_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_15 iphorm_2_15_2\" type=\"checkbox\" name=\"iphorm_2_15[]\" id=\"iphorm_2_15_6acc3aa32fb41_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_2_16-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_2_16-element-spacer\">\n        <label for=\"iphorm_2_16_6acc3aa32fb41\" class=\"iphorm_2_16-outer-label\" >Your profession<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_2_16-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_2_16\" id=\"iphorm_2_16_6acc3aa32fb41\" type=\"text\" name=\"iphorm_2_16\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_2_17-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_2_17-element-spacer\">\n        <label for=\"iphorm_2_17_6acc3aa32fb41\" class=\"iphorm_2_17-outer-label\" >Your hobbies:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_2_17-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_2_17\" id=\"iphorm_2_17_6acc3aa32fb41\" type=\"text\" name=\"iphorm_2_17\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_2_18-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_2_18-element-spacer\">\n        <label class=\"iphorm_2_18-outer-label\" >Marital status:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_2_18-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_2_18-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_18-input-li\" >\n                    <label for=\"iphorm_2_18_6acc3aa32fb41_1\"  class=\"iphorm_2_18_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_18 iphorm_2_18_1\" type=\"checkbox\" name=\"iphorm_2_18[]\" id=\"iphorm_2_18_6acc3aa32fb41_1\" value=\"Married\"  \/>\n                        Married                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_18-input-li\" >\n                    <label for=\"iphorm_2_18_6acc3aa32fb41_2\"  class=\"iphorm_2_18_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_18 iphorm_2_18_2\" type=\"checkbox\" name=\"iphorm_2_18[]\" id=\"iphorm_2_18_6acc3aa32fb41_2\" value=\"Single\"  \/>\n                        Single                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_18-input-li\" >\n                    <label for=\"iphorm_2_18_6acc3aa32fb41_3\"  class=\"iphorm_2_18_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_18 iphorm_2_18_3\" type=\"checkbox\" name=\"iphorm_2_18[]\" id=\"iphorm_2_18_6acc3aa32fb41_3\" value=\"Divorced\"  \/>\n                        Divorced                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_18-input-li\" >\n                    <label for=\"iphorm_2_18_6acc3aa32fb41_4\"  class=\"iphorm_2_18_4_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_18 iphorm_2_18_4\" type=\"checkbox\" name=\"iphorm_2_18[]\" id=\"iphorm_2_18_6acc3aa32fb41_4\" value=\"Widow(er)\"  \/>\n                        Widow(er)                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_2_19-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_2_19-element-spacer\">\n        <label class=\"iphorm_2_19-outer-label\" >Children<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_2_19-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_2_19-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_19-input-li\" >\n                    <label for=\"iphorm_2_19_6acc3aa32fb41_1\"  class=\"iphorm_2_19_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_19 iphorm_2_19_1\" type=\"checkbox\" name=\"iphorm_2_19[]\" id=\"iphorm_2_19_6acc3aa32fb41_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_19-input-li\" >\n                    <label for=\"iphorm_2_19_6acc3aa32fb41_2\"  class=\"iphorm_2_19_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_19 iphorm_2_19_2\" type=\"checkbox\" name=\"iphorm_2_19[]\" id=\"iphorm_2_19_6acc3aa32fb41_2\" value=\"None\"  \/>\n                        None                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_2_20-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_2_20-element-spacer\">\n        <label for=\"iphorm_2_20_6acc3aa32fb41\" class=\"iphorm_2_20-outer-label\" >Number of children<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_2_20-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_2_20\" id=\"iphorm_2_20_6acc3aa32fb41\" type=\"text\" name=\"iphorm_2_20\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_2_35-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_2_35-element-spacer\">\n        <label class=\"iphorm_2_35-outer-label\" >For an astrological prediction of which specific period you are interested in?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_2_35-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_2_35-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_35-input-li\" >\n                    <label for=\"iphorm_2_35_6acc3aa32fb41_1\"  class=\"iphorm_2_35_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_35 iphorm_2_35_1\" type=\"checkbox\" name=\"iphorm_2_35[]\" id=\"iphorm_2_35_6acc3aa32fb41_1\" value=\"For a month\"  \/>\n                        For a month                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_35-input-li\" >\n                    <label for=\"iphorm_2_35_6acc3aa32fb41_2\"  class=\"iphorm_2_35_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_35 iphorm_2_35_2\" type=\"checkbox\" name=\"iphorm_2_35[]\" id=\"iphorm_2_35_6acc3aa32fb41_2\" value=\"This and next year\"  \/>\n                        This and next year                    <\/label>\n                <\/div>\n                        <\/div>\n                <p class=\"iphorm-description\" >Attention! An astrological prediction for a year is made from your birthday on this year to your birthday next year.<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_2_36-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_2_36-element-spacer\">\n        <label for=\"iphorm_2_36_6acc3aa32fb41\" class=\"iphorm_2_36-outer-label\" >Number of month:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_2_36-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_2_36\" id=\"iphorm_2_36_6acc3aa32fb41\" type=\"text\" name=\"iphorm_2_36\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-textarea iphorm_2_21-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-textarea iphorm_2_21-element-spacer\">\n        <label for=\"iphorm_2_21_6acc3aa32fb41\" class=\"iphorm_2_21-outer-label\" >You can write down the specific issues you are interested in or what specifically the astrologer should take into account when analyzing the Horoscope:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-textarea iphorm_2_21-input-wrap\" >\n            <textarea class=\"iphorm-element-textarea  iphorm_2_21\" id=\"iphorm_2_21_6acc3aa32fb41\" name=\"iphorm_2_21\"   rows=\"5\" cols=\"25\"><\/textarea>\n                <p class=\"iphorm-description\" >The clearer and more specific you formulate the questions and issues you are interested in, the more accurately we will be able to present information to you on the basis of your horoscope.<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_2_22-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_2_22-element-spacer\">\n        <label class=\"iphorm_2_22-outer-label\" >May we contact you should the astrologer have any questions regarding more specific data?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_2_22-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_2_22-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_22-input-li\" >\n                    <label for=\"iphorm_2_22_6acc3aa32fb41_1\"  class=\"iphorm_2_22_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_22 iphorm_2_22_1\" type=\"checkbox\" name=\"iphorm_2_22[]\" id=\"iphorm_2_22_6acc3aa32fb41_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_22-input-li\" >\n                    <label for=\"iphorm_2_22_6acc3aa32fb41_2\"  class=\"iphorm_2_22_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_22 iphorm_2_22_2\" type=\"checkbox\" name=\"iphorm_2_22[]\" id=\"iphorm_2_22_6acc3aa32fb41_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_2_23-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_2_23-element-spacer\">\n        <label for=\"iphorm_2_23_6acc3aa32fb41\" class=\"iphorm_2_23-outer-label\" >Telephone number:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_2_23-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_2_23\" id=\"iphorm_2_23_6acc3aa32fb41\" type=\"text\" name=\"iphorm_2_23\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_2_24-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_2_24-element-spacer\">\n        <label for=\"iphorm_2_24_6acc3aa32fb41\" class=\"iphorm_2_24-outer-label\" >E-mail:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_2_24-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_2_24\" id=\"iphorm_2_24_6acc3aa32fb41\" type=\"text\" name=\"iphorm_2_24\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_2_25-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_2_25-element-spacer\">\n        <label class=\"iphorm_2_25-outer-label\" >Please state in which way you wish to receive the Horoscope you have ordered in a written form:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_2_25-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_2_25-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_25-input-li\" >\n                    <label for=\"iphorm_2_25_6acc3aa32fb41_1\"  class=\"iphorm_2_25_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_25 iphorm_2_25_1\" type=\"checkbox\" name=\"iphorm_2_25[]\" id=\"iphorm_2_25_6acc3aa32fb41_1\" value=\"By e-mail\"  \/>\n                        By e-mail                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_25-input-li\" >\n                    <label for=\"iphorm_2_25_6acc3aa32fb41_2\"  class=\"iphorm_2_25_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_25 iphorm_2_25_2\" type=\"checkbox\" name=\"iphorm_2_25[]\" id=\"iphorm_2_25_6acc3aa32fb41_2\" value=\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"  \/>\n                        By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_2_26-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_2_26-element-spacer\">\n        <label for=\"iphorm_2_26_6acc3aa32fb41\" class=\"iphorm_2_26-outer-label\" >State e-mail address at which you wish to receive the horoscope in a written form:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_2_26-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_2_26\" id=\"iphorm_2_26_6acc3aa32fb41\" type=\"text\" name=\"iphorm_2_26\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-html iphorm_2_28-element-wrap iphorm-clearfix\">\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-html iphorm_2_28-element-spacer\">\n        Please state your exact address at which we could send the Horoscope:    <\/div>\n<\/div>\n<div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_2_27-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_2_27-element-spacer\">\n        <label for=\"iphorm_2_27_6acc3aa32fb41\" class=\"iphorm_2_27-outer-label\" >Country:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_2_27-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_2_27\" id=\"iphorm_2_27_6acc3aa32fb41\" type=\"text\" name=\"iphorm_2_27\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_2_29-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_2_29-element-spacer\">\n        <label for=\"iphorm_2_29_6acc3aa32fb41\" class=\"iphorm_2_29-outer-label\" >City:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_2_29-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_2_29\" id=\"iphorm_2_29_6acc3aa32fb41\" type=\"text\" name=\"iphorm_2_29\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_2_30-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_2_30-element-spacer\">\n        <label for=\"iphorm_2_30_6acc3aa32fb41\" class=\"iphorm_2_30-outer-label\" >Street:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_2_30-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_2_30\" id=\"iphorm_2_30_6acc3aa32fb41\" type=\"text\" name=\"iphorm_2_30\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_2_31-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_2_31-element-spacer\">\n        <label for=\"iphorm_2_31_6acc3aa32fb41\" class=\"iphorm_2_31-outer-label\" >House:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_2_31-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_2_31\" id=\"iphorm_2_31_6acc3aa32fb41\" type=\"text\" name=\"iphorm_2_31\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_2_32-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_2_32-element-spacer\">\n        <label for=\"iphorm_2_32_6acc3aa32fb41\" class=\"iphorm_2_32-outer-label\" >Apartment:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_2_32-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_2_32\" id=\"iphorm_2_32_6acc3aa32fb41\" type=\"text\" name=\"iphorm_2_32\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_2_33-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_2_33-element-spacer\">\n        <label class=\"iphorm_2_33-outer-label\" >Order confirmation:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_2_33-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_2_33-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_2_33-input-li\" >\n                    <label for=\"iphorm_2_33_6acc3aa32fb41_1\"  class=\"iphorm_2_33_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_2_33 iphorm_2_33_1\" type=\"checkbox\" name=\"iphorm_2_33[]\" id=\"iphorm_2_33_6acc3aa32fb41_1\" value=\"I order a horoscope and guarantee that the data presented in the registration form is true. \"  \/>\n                        I order a horoscope and guarantee that the data presented in the registration form is true.                     <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-recaptcha g-recaptcha-response-element-wrap iphorm_2_37-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-required\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-captcha g-recaptcha-response-element-spacer\">\n        <label class=\"g-recaptcha-response-outer-label\" >Type the words<span class=\"iphorm-required\">(required)<\/span><\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-recaptcha g-recaptcha-response-input-wrap\" >\n                            <div id=\"iphorm_2_37_6acc3aa32fb41\" class=\"iphorm-recaptcha\" data-unique-id=\"iphorm_2_37_6acc3aa32fb41\" data-config=\"{&quot;sitekey&quot;:&quot;6LedJT8UAAAAAF98QMjpclkDUi0x8zoTC2M7u2VB&quot;,&quot;theme&quot;:&quot;light&quot;,&quot;type&quot;:&quot;image&quot;,&quot;size&quot;:&quot;normal&quot;}\"><\/div>\n                <noscript>\n                  <div style=\"width: 302px; height: 352px;\">\n                    <div style=\"width: 302px; height: 352px; position: relative;\">\n                      <div style=\"width: 302px; height: 352px; position: absolute;\">\n                        <iframe src=\"https:\/\/www.google.com\/recaptcha\/api\/fallback?k=6LedJT8UAAAAAF98QMjpclkDUi0x8zoTC2M7u2VB\"\n                                frameborder=\"0\" scrolling=\"no\"\n                                style=\"width: 302px; height:352px; border-style: none;\">\n                        <\/iframe>\n                      <\/div>\n                      <div style=\"width: 250px; height: 80px; position: absolute; border-style: none;\n                                  bottom: 21px; left: 25px; margin: 0px; padding: 0px; right: 25px;\">\n                        <textarea name=\"g-recaptcha-response\" class=\"g-recaptcha-response\"\n                                  style=\"width: 250px; height: 80px; border: 1px solid #c1c1c1;\n                                         margin: 0px; padding: 0px; resize: none;\"><\/textarea>\n                      <\/div>\n                    <\/div>\n                  <\/div>\n                <\/noscript>\n                                <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-hidden\">\n    <label>This field should be left blank<input type=\"text\" name=\"iphorm_2_0\" \/><\/label>\n<\/div>                <div class=\"iphorm-submit-wrap iphorm-submit-wrap-2 iphorm-clearfix\" >\n                    <div class=\"iphorm-submit-input-wrap iphorm-submit-input-wrap-2\" >\n                        <button class=\"iphorm-submit-element\" type=\"submit\" name=\"iphorm_submit\" ><span ><em >U\u017dSISAKYTI<\/em><\/span><\/button>\n                    <\/div>\n                    <div class=\"iphorm-loading-wrap\"><span class=\"iphorm-loading\">Please wait...<\/span><\/div>\n                <\/div>\n            <\/div>\n                                                                        <div class=\"iphorm-success-message iphorm-hidden\" ><\/div>\n                                    <\/div>\n            <\/form>\n    <script type=\"text\/javascript\">\n    jQuery('#iphorm-outer-6acc3aa32fb41 script').remove();\n    <\/script>\n<\/div>\t<\/div>\r\n\r\n\t<div class=\"hidden-form form-PS\">\r\n\t<div id=\"iphorm-outer-6acc3aa33211b\" class=\"iphorm-outer iphorm-outer-3 iphorm-uniform-theme-default iphorm-theme-light-light iphorm-has-logic\" >\n    <script type=\"text\/javascript\">\n        jQuery(document).ready(function($) {\n                            iPhorm.logic[3] = {\"logic\":{\"14\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"13\",\"operator\":\"eq\",\"value\":\"Secondary-special\"},{\"element_id\":\"13\",\"operator\":\"eq\",\"value\":\"Higher\"}]},\"16\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"15\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"20\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"19\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"44\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"43\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"47\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"46\",\"operator\":\"eq\",\"value\":\"Secondary-special\"},{\"element_id\":\"46\",\"operator\":\"eq\",\"value\":\"Higher\"}]},\"50\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"49\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"23\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"22\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"24\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"22\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"26\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By e-mail\"}]},\"28\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"27\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"29\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"30\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"31\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"32\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]}},\"dependents\":{\"13\":[14,14],\"15\":[16],\"19\":[20],\"43\":[44],\"46\":[47,47],\"49\":[50],\"22\":[23,24],\"25\":[26,28,27,29,30,31,32]},\"animate\":true};\n                        $('#iphorm-6acc3aa33211b').iPhorm({\"id\":3,\"uniqueId\":\"6acc3aa33211b\",\"useAjax\":true,\"successMessageTimeout\":160,\"resetFormValues\":\"\",\"clElementIds\":[14,16,20,44,47,50,23,24,26,28,27,29,30,31,32],\"clDependentElementIds\":[13,15,19,43,46,49,22,25],\"centerFancybox\":true,\"centerFancyboxSpeed\":true});\n                        if ($.isFunction($.fn.qtip)) {\n                $('.iphorm-tooltip-hover', iPhorm.instance.$form).qtip({\n                    style: {\n                        classes: 'qtip-plain 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'unfocus'\n                    }\n                });\n                $('.iphorm-tooltip-icon-hover', iPhorm.instance.$form).qtip({\n                    style: {\n                        classes: 'qtip-plain qtip-shadow'\n                    },\n                    position: {\n                        my: 'left center',\n                        at: 'right center',\n                        viewport: $(window),\n                        adjust: {\n                            method: 'shift'\n                        }\n                    },\n                    content: {\n                        text: function (api) {\n                            return $(this).find('.iphorm-tooltip-icon-content').html();\n                        }\n                    }\n                });\n                $('.iphorm-tooltip-icon-click', iPhorm.instance.$form).qtip({\n                    style: {\n                        classes: 'qtip-plain qtip-shadow'\n                    },\n                    position: {\n                        my: 'left center',\n                        at: 'right center',\n                        viewport: $(window),\n                        adjust: {\n                            method: 'shift'\n                        }\n                    },\n                    show: {\n                        event: 'click'\n                    },\n                    hide: {\n                        event: 'unfocus'\n                    },\n                    content: {\n                        text: function (api) {\n                            return $(this).find('.iphorm-tooltip-icon-content').html();\n                        }\n                    }\n                });\n                $('.iphorm-labels-inside > .iphorm-element-spacer > label').hover(function () {\n                    $(this).siblings('.iphorm-input-wrap').find('.iphorm-tooltip-hover').qtip('show');\n                }, function () {\n                    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class=\"iphorm iphorm-form-3\" action=\"\/en\/wp-json\/wp\/v2\/pages\/40#iphorm-6acc3aa33211b\" method=\"post\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\">\n        <div class=\"iphorm-inner iphorm-inner-3\" >\n            <input type=\"hidden\" name=\"iphorm_id\" value=\"3\" \/>\n            <input type=\"hidden\" name=\"iphorm_uid\" value=\"6acc3aa33211b\" \/>\n            <input type=\"hidden\" name=\"form_url\" value=\"http:\/\/www.e-astrology.eu\/en\/wp-json\/wp\/v2\/pages\/40\" \/>\n            <input type=\"hidden\" name=\"referring_url\" value=\"\" \/>\n            <input type=\"hidden\" name=\"post_id\" value=\"\" \/>\n            <input type=\"hidden\" name=\"post_title\" value=\"\" \/>\n                            <h3 class=\"iphorm-title\" >COMPATIBILITY OF PARTNERS \u2013 ORDER FORM<\/h3>\n                                                <div class=\"iphorm-elements iphorm-elements-3 iphorm-clearfix\" >\n                Attention! Please complete all boxes of the questionnaire very carefully. The Centre guarantees that all information stated in the registration form and information concerning your horoscope is confidential and it shall not be disclosed to any third parties in any case. \n<br><\/br><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_3_55-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_3_55-element-spacer\">\n        <label class=\"iphorm_3_55-outer-label\" >Type (kind) of ORAL consultation:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_3_55-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_3_55-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_55-input-li\" >\n                    <label for=\"iphorm_3_55_6acc3aa33211b_1\"  class=\"iphorm_3_55_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_55 iphorm_3_55_1\" type=\"checkbox\" name=\"iphorm_3_55[]\" id=\"iphorm_3_55_6acc3aa33211b_1\" value=\"Consultation on SKYPE (cost 50 eur)\"  \/>\n                        Consultation on SKYPE (cost 50 eur)                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_55-input-li\" >\n                    <label for=\"iphorm_3_55_6acc3aa33211b_2\"  class=\"iphorm_3_55_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_55 iphorm_3_55_2\" type=\"checkbox\" name=\"iphorm_3_55[]\" id=\"iphorm_3_55_6acc3aa33211b_2\" value=\"Personal visit\/meeting (only in Vilnius, Lithuania)\"  \/>\n                        Personal visit\/meeting (only in Vilnius, Lithuania)                    <\/label>\n                <\/div>\n                        <\/div>\n                <p class=\"iphorm-description\" >Attention! The cost of personal consultation (meeting with the astrologer) is determined individually.<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_3_56-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_3_56-element-spacer\">\n        <label class=\"iphorm_3_56-outer-label\" >Order of the Horoscope in a written form:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_3_56-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_3_56-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_56-input-li\" >\n                    <label for=\"iphorm_3_56_6acc3aa33211b_1\"  class=\"iphorm_3_56_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_56 iphorm_3_56_1\" type=\"checkbox\" name=\"iphorm_3_56[]\" id=\"iphorm_3_56_6acc3aa33211b_1\" value=\"I want to order the Horoscope in a WRITTEN form\"  \/>\n                        I want to order the Horoscope in a WRITTEN form                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_3_51-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_3_51-element-spacer\">\n        <label class=\"iphorm_3_51-outer-label\" >I want to order the horoscope:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_3_51-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_3_51-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_51-input-li\" >\n                    <label for=\"iphorm_3_51_6acc3aa33211b_1\"  class=\"iphorm_3_51_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_51 iphorm_3_51_1\" type=\"checkbox\" name=\"iphorm_3_51[]\" id=\"iphorm_3_51_6acc3aa33211b_1\" value=\"in English Language \u2013 120 eur\"  \/>\n                        in English Language \u2013 120 eur                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_51-input-li\" >\n                    <label for=\"iphorm_3_51_6acc3aa33211b_2\"  class=\"iphorm_3_51_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_51 iphorm_3_51_2\" type=\"checkbox\" name=\"iphorm_3_51[]\" id=\"iphorm_3_51_6acc3aa33211b_2\" value=\"in Russian Language \u2013 70 eur\"  \/>\n                        in Russian Language \u2013 70 eur                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_51-input-li\" >\n                    <label for=\"iphorm_3_51_6acc3aa33211b_3\"  class=\"iphorm_3_51_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_51 iphorm_3_51_3\" type=\"checkbox\" name=\"iphorm_3_51[]\" id=\"iphorm_3_51_6acc3aa33211b_3\" value=\"in Lithuanian Language \u2013 120 eur\"  \/>\n                        in Lithuanian Language \u2013 120 eur                    <\/label>\n                <\/div>\n                        <\/div>\n                <p class=\"iphorm-description\" >The cost of a written horoscope depends on the chosen language<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_2-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_2-element-spacer\">\n        <label for=\"iphorm_3_2_6acc3aa33211b\" class=\"iphorm_3_2-outer-label\" >Name and surname:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_2-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_2\" id=\"iphorm_3_2_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_2\"  value=\"\"  \/>\n                <p class=\"iphorm-description\" >* We need your name and surname to check and receive the bank transfer (payment of your order).<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_3_3-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_3_3-element-spacer\">\n        <label class=\"iphorm_3_3-outer-label\" >Sex:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_3_3-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_3_3-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_3-input-li\" >\n                    <label for=\"iphorm_3_3_6acc3aa33211b_1\"  class=\"iphorm_3_3_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_3 iphorm_3_3_1\" type=\"checkbox\" name=\"iphorm_3_3[]\" id=\"iphorm_3_3_6acc3aa33211b_1\" value=\"Male\"  \/>\n                        Male                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_3-input-li\" >\n                    <label for=\"iphorm_3_3_6acc3aa33211b_2\"  class=\"iphorm_3_3_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_3 iphorm_3_3_2\" type=\"checkbox\" name=\"iphorm_3_3[]\" id=\"iphorm_3_3_6acc3aa33211b_2\" value=\"Female\"  \/>\n                        Female                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-date iphorm_3_4-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\r\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-date iphorm_3_4-element-spacer\">\r\n        <label id=\"iphorm_3_4_6acc3aa33211b_date_label\" class=\"iphorm_3_4-outer-label\" >Date of birth:<\/label>        <div id=\"iphorm_3_4_6acc3aa33211b\" class=\"iphorm-input-wrap iphorm-input-wrap-date iphorm_3_4-input-wrap\" >\r\n        \t<div class=\"iphorm-clearfix\">\r\n                <div class=\"iphorm-input-wrap-date-select-wrap\">\r\n                                                                                <label id=\"iphorm_3_4_6acc3aa33211b_day_label\" class=\"iphorm-screen-reader-text\">Day<\/label>\r\n                    <select id=\"iphorm_3_4_6acc3aa33211b_day\" name=\"iphorm_3_4[day]\" class=\"iphorm_3_4-input-day\" aria-labelledby=\"iphorm_3_4_6acc3aa33211b_date_label iphorm_3_4_6acc3aa33211b_day_label\" >\r\n                        <option value=\"\">Day<\/option>                                                    <option value=\"1\" >1<\/option>\r\n                                                    <option value=\"2\" >2<\/option>\r\n                                                    <option value=\"3\" >3<\/option>\r\n                                                    <option value=\"4\" >4<\/option>\r\n                                                    <option value=\"5\" >5<\/option>\r\n                                                    <option value=\"6\" >6<\/option>\r\n                                                    <option value=\"7\" >7<\/option>\r\n                                                    <option value=\"8\" >8<\/option>\r\n                                                    <option value=\"9\" >9<\/option>\r\n                                                    <option value=\"10\" >10<\/option>\r\n                                                    <option value=\"11\" >11<\/option>\r\n                                                    <option value=\"12\" >12<\/option>\r\n                                                    <option value=\"13\" >13<\/option>\r\n                                                    <option value=\"14\" >14<\/option>\r\n                                                    <option value=\"15\" >15<\/option>\r\n                                                    <option value=\"16\" >16<\/option>\r\n                                                    <option value=\"17\" >17<\/option>\r\n                                                    <option value=\"18\" >18<\/option>\r\n                                                    <option value=\"19\" >19<\/option>\r\n                                                    <option value=\"20\" >20<\/option>\r\n                                                    <option value=\"21\" >21<\/option>\r\n                                                    <option value=\"22\" >22<\/option>\r\n                                                    <option value=\"23\" >23<\/option>\r\n                                                    <option value=\"24\" >24<\/option>\r\n                                                    <option value=\"25\" >25<\/option>\r\n                                                    <option value=\"26\" >26<\/option>\r\n                                                    <option value=\"27\" >27<\/option>\r\n                                                    <option value=\"28\" >28<\/option>\r\n                                                    <option value=\"29\" >29<\/option>\r\n                                                    <option value=\"30\" >30<\/option>\r\n                                                    <option value=\"31\" >31<\/option>\r\n                                            <\/select>\r\n                                        <label id=\"iphorm_3_4_6acc3aa33211b_month_label\" class=\"iphorm-screen-reader-text\">Month<\/label>\r\n                    <select id=\"iphorm_3_4_6acc3aa33211b_month\" name=\"iphorm_3_4[month]\" class=\"iphorm_3_4-input-month\" aria-labelledby=\"iphorm_3_4_6acc3aa33211b_date_label iphorm_3_4_6acc3aa33211b_month_label\" >\r\n                        <option value=\"\">Month<\/option>                                                    <option value=\"1\" >1<\/option>\r\n                                                    <option value=\"2\" >2<\/option>\r\n                                                    <option value=\"3\" >3<\/option>\r\n                                                    <option value=\"4\" >4<\/option>\r\n                                                    <option value=\"5\" >5<\/option>\r\n                                                    <option value=\"6\" >6<\/option>\r\n                                                    <option value=\"7\" >7<\/option>\r\n                                                    <option value=\"8\" >8<\/option>\r\n                                                    <option value=\"9\" >9<\/option>\r\n                                                    <option value=\"10\" >10<\/option>\r\n                                                    <option value=\"11\" >11<\/option>\r\n                                                    <option value=\"12\" >12<\/option>\r\n                                            <\/select>\r\n                                        <label id=\"iphorm_3_4_6acc3aa33211b_year_label\" class=\"iphorm-screen-reader-text\">Year<\/label>\r\n                    <select id=\"iphorm_3_4_6acc3aa33211b_year\" name=\"iphorm_3_4[year]\" class=\"iphorm_3_4-input-year\" aria-labelledby=\"iphorm_3_4_6acc3aa33211b_date_label iphorm_3_4_6acc3aa33211b_year_label\" >\r\n                        <option value=\"\">Year<\/option>                                                                                    <option value=\"2030\" >2030<\/option>\r\n                                                            <option value=\"2029\" >2029<\/option>\r\n                                                            <option value=\"2028\" >2028<\/option>\r\n                                                            <option value=\"2027\" >2027<\/option>\r\n                                                            <option value=\"2026\" >2026<\/option>\r\n                                                            <option value=\"2025\" >2025<\/option>\r\n                                                            <option value=\"2024\" >2024<\/option>\r\n                                                            <option value=\"2023\" >2023<\/option>\r\n                                                            <option value=\"2022\" >2022<\/option>\r\n                                                            <option value=\"2021\" >2021<\/option>\r\n                                                            <option value=\"2020\" >2020<\/option>\r\n                                                            <option value=\"2019\" >2019<\/option>\r\n                                                            <option value=\"2018\" >2018<\/option>\r\n                                                            <option value=\"2017\" >2017<\/option>\r\n                                                            <option value=\"2016\" >2016<\/option>\r\n                                                            <option value=\"2015\" >2015<\/option>\r\n                                                            <option value=\"2014\" >2014<\/option>\r\n                                                            <option value=\"2013\" >2013<\/option>\r\n                                                            <option value=\"2012\" >2012<\/option>\r\n                                                            <option value=\"2011\" >2011<\/option>\r\n                                                            <option value=\"2010\" >2010<\/option>\r\n                                                            <option value=\"2009\" >2009<\/option>\r\n                                                            <option value=\"2008\" >2008<\/option>\r\n                                                            <option value=\"2007\" >2007<\/option>\r\n                                                            <option value=\"2006\" >2006<\/option>\r\n                                                            <option value=\"2005\" >2005<\/option>\r\n                                                            <option value=\"2004\" >2004<\/option>\r\n                                                            <option value=\"2003\" >2003<\/option>\r\n                                                            <option value=\"2002\" >2002<\/option>\r\n                                                            <option value=\"2001\" >2001<\/option>\r\n                                                            <option value=\"2000\" >2000<\/option>\r\n                                                            <option value=\"1999\" >1999<\/option>\r\n                                                            <option value=\"1998\" >1998<\/option>\r\n                                                            <option value=\"1997\" >1997<\/option>\r\n                                                            <option value=\"1996\" >1996<\/option>\r\n                                                            <option value=\"1995\" >1995<\/option>\r\n                                                            <option value=\"1994\" >1994<\/option>\r\n                                                            <option value=\"1993\" >1993<\/option>\r\n                                                            <option value=\"1992\" >1992<\/option>\r\n                                                            <option value=\"1991\" >1991<\/option>\r\n                                                            <option value=\"1990\" >1990<\/option>\r\n                                                            <option value=\"1989\" >1989<\/option>\r\n                                                            <option value=\"1988\" >1988<\/option>\r\n                                                            <option value=\"1987\" >1987<\/option>\r\n                                                            <option value=\"1986\" >1986<\/option>\r\n                                                            <option value=\"1985\" >1985<\/option>\r\n                                                            <option value=\"1984\" >1984<\/option>\r\n                                                            <option value=\"1983\" >1983<\/option>\r\n                                                            <option value=\"1982\" >1982<\/option>\r\n                                                            <option value=\"1981\" >1981<\/option>\r\n                                                            <option value=\"1980\" >1980<\/option>\r\n                                                            <option value=\"1979\" >1979<\/option>\r\n                                                            <option value=\"1978\" >1978<\/option>\r\n                                                            <option value=\"1977\" >1977<\/option>\r\n                                                            <option value=\"1976\" >1976<\/option>\r\n                                                            <option value=\"1975\" >1975<\/option>\r\n                                                            <option value=\"1974\" >1974<\/option>\r\n                                                            <option value=\"1973\" >1973<\/option>\r\n                                                            <option value=\"1972\" >1972<\/option>\r\n                                                            <option value=\"1971\" >1971<\/option>\r\n                                                            <option value=\"1970\" >1970<\/option>\r\n                                                            <option value=\"1969\" >1969<\/option>\r\n                                                            <option value=\"1968\" >1968<\/option>\r\n                                                            <option value=\"1967\" >1967<\/option>\r\n                                                            <option value=\"1966\" >1966<\/option>\r\n                                                            <option value=\"1965\" >1965<\/option>\r\n                                                            <option value=\"1964\" >1964<\/option>\r\n                                                            <option value=\"1963\" >1963<\/option>\r\n                                                            <option value=\"1962\" >1962<\/option>\r\n                                                            <option value=\"1961\" >1961<\/option>\r\n                                                            <option value=\"1960\" >1960<\/option>\r\n                                                            <option value=\"1959\" >1959<\/option>\r\n                                                            <option value=\"1958\" >1958<\/option>\r\n                                                            <option value=\"1957\" >1957<\/option>\r\n                                                            <option value=\"1956\" >1956<\/option>\r\n                                                            <option value=\"1955\" >1955<\/option>\r\n                                                            <option value=\"1954\" >1954<\/option>\r\n                                                            <option value=\"1953\" >1953<\/option>\r\n                                                            <option value=\"1952\" >1952<\/option>\r\n                                                            <option value=\"1951\" >1951<\/option>\r\n                                                            <option value=\"1950\" >1950<\/option>\r\n                                                            <option value=\"1949\" >1949<\/option>\r\n                                                            <option value=\"1948\" >1948<\/option>\r\n                                                            <option value=\"1947\" >1947<\/option>\r\n                                                            <option value=\"1946\" >1946<\/option>\r\n                                                            <option value=\"1945\" >1945<\/option>\r\n                                                            <option value=\"1944\" >1944<\/option>\r\n                                                            <option value=\"1943\" >1943<\/option>\r\n                                                            <option value=\"1942\" >1942<\/option>\r\n                                                            <option value=\"1941\" >1941<\/option>\r\n                                                            <option value=\"1940\" >1940<\/option>\r\n                                                            <option value=\"1939\" >1939<\/option>\r\n                                                            <option value=\"1938\" >1938<\/option>\r\n                                                            <option value=\"1937\" >1937<\/option>\r\n                                                            <option value=\"1936\" >1936<\/option>\r\n                                                            <option value=\"1935\" >1935<\/option>\r\n                                                            <option value=\"1934\" >1934<\/option>\r\n                                                            <option value=\"1933\" >1933<\/option>\r\n                                                            <option value=\"1932\" >1932<\/option>\r\n                                                            <option value=\"1931\" >1931<\/option>\r\n                                                            <option value=\"1930\" >1930<\/option>\r\n                                                            <option value=\"1929\" >1929<\/option>\r\n                                                            <option value=\"1928\" >1928<\/option>\r\n                                                            <option value=\"1927\" >1927<\/option>\r\n                                                            <option value=\"1926\" >1926<\/option>\r\n                                                            <option value=\"1925\" >1925<\/option>\r\n                                                            <option value=\"1924\" >1924<\/option>\r\n                                                            <option value=\"1923\" >1923<\/option>\r\n                                                            <option value=\"1922\" >1922<\/option>\r\n                                                            <option value=\"1921\" >1921<\/option>\r\n                                                            <option value=\"1920\" >1920<\/option>\r\n                                                            <option value=\"1919\" >1919<\/option>\r\n                                                            <option value=\"1918\" >1918<\/option>\r\n                                                            <option value=\"1917\" >1917<\/option>\r\n                                                            <option value=\"1916\" >1916<\/option>\r\n                                                            <option value=\"1915\" >1915<\/option>\r\n                                                            <option value=\"1914\" >1914<\/option>\r\n                                                            <option value=\"1913\" >1913<\/option>\r\n                                                            <option value=\"1912\" >1912<\/option>\r\n                                                            <option value=\"1911\" >1911<\/option>\r\n                                                            <option value=\"1910\" >1910<\/option>\r\n                                                            <option value=\"1909\" >1909<\/option>\r\n                                                            <option value=\"1908\" >1908<\/option>\r\n                                                            <option value=\"1907\" >1907<\/option>\r\n                                                            <option value=\"1906\" >1906<\/option>\r\n                                                            <option value=\"1905\" >1905<\/option>\r\n                                                            <option value=\"1904\" >1904<\/option>\r\n                                                            <option value=\"1903\" >1903<\/option>\r\n                                                            <option value=\"1902\" >1902<\/option>\r\n                                                            <option value=\"1901\" >1901<\/option>\r\n                                                            <option value=\"1900\" >1900<\/option>\r\n                                                                        <\/select>\r\n                <\/div>\r\n                            <\/div>\r\n                    <\/div>\r\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\r\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-time iphorm_3_5-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-time iphorm_3_5-element-spacer\">\n        <label id=\"iphorm_3_5_6acc3aa33211b_time_label\" class=\"iphorm_3_5-outer-label\" >Exact time of birth (hours and minutes):<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-date iphorm_3_5-input-wrap\" >\n            <label id=\"iphorm_3_5_6acc3aa33211b_hour_label\" class=\"iphorm-screen-reader-text\">Hour<\/label>\n            <select id=\"iphorm_3_5_6acc3aa33211b_hour\"  name=\"iphorm_3_5[hour]\" class=\"iphorm_3_5-input-hour\" aria-labelledby=\"iphorm_3_5_6acc3aa33211b_time_label iphorm_3_5_6acc3aa33211b_hour_label\" >\n                <option value=\"\">HH<\/option>                                                                                    <option value=\"00\" >00<\/option>\n                                                                    <option value=\"01\" >01<\/option>\n                                                                    <option value=\"02\" >02<\/option>\n                                                                    <option value=\"03\" >03<\/option>\n                                                                    <option value=\"04\" >04<\/option>\n                                                                    <option value=\"05\" >05<\/option>\n                                                                    <option value=\"06\" >06<\/option>\n                                                                    <option value=\"07\" >07<\/option>\n                                                                    <option value=\"08\" >08<\/option>\n                                                                    <option value=\"09\" >09<\/option>\n                                                                    <option value=\"10\" >10<\/option>\n                                                                    <option value=\"11\" >11<\/option>\n                                                                    <option value=\"12\"  selected='selected'>12<\/option>\n                                                                    <option value=\"13\" >13<\/option>\n                                                                    <option value=\"14\" >14<\/option>\n                                                                    <option value=\"15\" >15<\/option>\n                                                                    <option value=\"16\" >16<\/option>\n                                                                    <option value=\"17\" >17<\/option>\n                                                                    <option value=\"18\" >18<\/option>\n                                                                    <option value=\"19\" >19<\/option>\n                                                                    <option value=\"20\" >20<\/option>\n                                                                    <option value=\"21\" >21<\/option>\n                                                                    <option value=\"22\" >22<\/option>\n                                                                    <option value=\"23\" >23<\/option>\n                                                <\/select>\n            <label id=\"iphorm_3_5_6acc3aa33211b_minute_label\" class=\"iphorm-screen-reader-text\">Minute<\/label>\n            <select id=\"iphorm_3_5_6acc3aa33211b_minute\" name=\"iphorm_3_5[minute]\" class=\"iphorm_3_5-input-minute\" aria-labelledby=\"iphorm_3_5_6acc3aa33211b_time_label iphorm_3_5_6acc3aa33211b_minute_label\" >\n                <option value=\"\">MM<\/option>                                                                                    <option value=\"00\"  selected='selected'>00<\/option>\n                                                                                                        <option value=\"01\" >01<\/option>\n                                                                                                        <option value=\"02\" >02<\/option>\n                                                                                                        <option value=\"03\" >03<\/option>\n                                                                                                        <option value=\"04\" >04<\/option>\n                                                                                                        <option value=\"05\" >05<\/option>\n                                                                                                        <option value=\"06\" >06<\/option>\n                                                                                                        <option value=\"07\" >07<\/option>\n                                                                                                        <option value=\"08\" >08<\/option>\n                                                                                                        <option value=\"09\" >09<\/option>\n                                                                                                        <option value=\"10\" >10<\/option>\n                                                                                                        <option value=\"11\" >11<\/option>\n                                                                                                        <option value=\"12\" >12<\/option>\n                                                                                                        <option value=\"13\" >13<\/option>\n                                                                                                        <option value=\"14\" >14<\/option>\n                                                                                                        <option value=\"15\" >15<\/option>\n                                                                                                        <option value=\"16\" >16<\/option>\n                                                                                                        <option value=\"17\" >17<\/option>\n                                                                                                        <option value=\"18\" >18<\/option>\n                                                                                                        <option value=\"19\" >19<\/option>\n                                                                                                        <option value=\"20\" >20<\/option>\n                                                                                                        <option value=\"21\" >21<\/option>\n                                                                                                        <option value=\"22\" >22<\/option>\n                                                                                                        <option value=\"23\" >23<\/option>\n                                                                                                        <option value=\"24\" >24<\/option>\n                                                                                                        <option value=\"25\" >25<\/option>\n                                                                                                        <option value=\"26\" >26<\/option>\n                                                                                                        <option value=\"27\" >27<\/option>\n                                                                                                        <option value=\"28\" >28<\/option>\n                                                                                                        <option value=\"29\" >29<\/option>\n                                                                                                        <option value=\"30\" >30<\/option>\n                                                                                                        <option value=\"31\" >31<\/option>\n                                                                                                        <option value=\"32\" >32<\/option>\n                                                                                                        <option value=\"33\" >33<\/option>\n                                                                                                        <option value=\"34\" >34<\/option>\n                                                                                                        <option value=\"35\" >35<\/option>\n                                                                                                        <option value=\"36\" >36<\/option>\n                                                                                                        <option value=\"37\" >37<\/option>\n                                                                                                        <option value=\"38\" >38<\/option>\n                                                                                                        <option value=\"39\" >39<\/option>\n                                                                                                        <option value=\"40\" >40<\/option>\n                                                                                                        <option value=\"41\" >41<\/option>\n                                                                                                        <option value=\"42\" >42<\/option>\n                                                                                                        <option value=\"43\" >43<\/option>\n                                                                                                        <option value=\"44\" >44<\/option>\n                                                                                                        <option value=\"45\" >45<\/option>\n                                                                                                        <option value=\"46\" >46<\/option>\n                                                                                                        <option value=\"47\" >47<\/option>\n                                                                                                        <option value=\"48\" >48<\/option>\n                                                                                                        <option value=\"49\" >49<\/option>\n                                                                                                        <option value=\"50\" >50<\/option>\n                                                                                                        <option value=\"51\" >51<\/option>\n                                                                                                        <option value=\"52\" >52<\/option>\n                                                                                                        <option value=\"53\" >53<\/option>\n                                                                                                        <option value=\"54\" >54<\/option>\n                                                                                                        <option value=\"55\" >55<\/option>\n                                                                                                        <option value=\"56\" >56<\/option>\n                                                                                                        <option value=\"57\" >57<\/option>\n                                                                                                        <option value=\"58\" >58<\/option>\n                                                                                                        <option value=\"59\" >59<\/option>\n                                                <\/select>\n                            <input type=\"hidden\" name=\"iphorm_3_5[ampm]\" value=\"\" \/>\n                                <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_3_6-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_3_6-element-spacer\">\n        <label class=\"iphorm_3_6-outer-label\" >If you don\u2019t know the exact time of birth, enter the approximate time and tick this box:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_3_6-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_3_6-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_6-input-li\" >\n                    <label for=\"iphorm_3_6_6acc3aa33211b_1\"  class=\"iphorm_3_6_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_6 iphorm_3_6_1\" type=\"checkbox\" name=\"iphorm_3_6[]\" id=\"iphorm_3_6_6acc3aa33211b_1\" value=\"I know the approximate time of birth only.\"  \/>\n                        I know the approximate time of birth only.                    <\/label>\n                <\/div>\n                        <\/div>\n                <p class=\"iphorm-description\" >Attention! If you don\u2019t know the exact time of birth, predictions may be inaccurate. The approximate time of birth can be stated for psychological and compatibility horoscopes. The more exact time of birth is stated, the more accurate the prediction is!<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_9-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_9-element-spacer\">\n        <label for=\"iphorm_3_9_6acc3aa33211b\" class=\"iphorm_3_9-outer-label\" >Exact country of birth:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_9-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_9\" id=\"iphorm_3_9_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_9\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_10-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_10-element-spacer\">\n        <label for=\"iphorm_3_10_6acc3aa33211b\" class=\"iphorm_3_10-outer-label\" >Exact city of birth:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_10-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_10\" id=\"iphorm_3_10_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_10\"  value=\"\"  \/>\n                <p class=\"iphorm-description\" >(If you were born in a small settlement, state the closest city.)<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_11-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_11-element-spacer\">\n        <label for=\"iphorm_3_11_6acc3aa33211b\" class=\"iphorm_3_11-outer-label\" >Country where you live in now:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_11-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_11\" id=\"iphorm_3_11_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_11\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_12-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_12-element-spacer\">\n        <label for=\"iphorm_3_12_6acc3aa33211b\" class=\"iphorm_3_12-outer-label\" >City where you live in now:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_12-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_12\" id=\"iphorm_3_12_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_12\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_3_13-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_3_13-element-spacer\">\n        <label class=\"iphorm_3_13-outer-label\" >Your education:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_3_13-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_3_13-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_13-input-li\" >\n                    <label for=\"iphorm_3_13_6acc3aa33211b_1\"  class=\"iphorm_3_13_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_13 iphorm_3_13_1\" type=\"checkbox\" name=\"iphorm_3_13[]\" id=\"iphorm_3_13_6acc3aa33211b_1\" value=\"Secondary\"  \/>\n                        Secondary                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_13-input-li\" >\n                    <label for=\"iphorm_3_13_6acc3aa33211b_2\"  class=\"iphorm_3_13_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_13 iphorm_3_13_2\" type=\"checkbox\" name=\"iphorm_3_13[]\" id=\"iphorm_3_13_6acc3aa33211b_2\" value=\"Secondary-special\"  \/>\n                        Secondary-special                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_13-input-li\" >\n                    <label for=\"iphorm_3_13_6acc3aa33211b_3\"  class=\"iphorm_3_13_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_13 iphorm_3_13_3\" type=\"checkbox\" name=\"iphorm_3_13[]\" id=\"iphorm_3_13_6acc3aa33211b_3\" value=\"Higher\"  \/>\n                        Higher                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_14-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_14-element-spacer\">\n        <label for=\"iphorm_3_14_6acc3aa33211b\" class=\"iphorm_3_14-outer-label\" >State the speciality:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_14-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_14\" id=\"iphorm_3_14_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_14\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_3_15-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_3_15-element-spacer\">\n        <label class=\"iphorm_3_15-outer-label\" >Are you employed at the moment?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_3_15-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_3_15-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_15-input-li\" >\n                    <label for=\"iphorm_3_15_6acc3aa33211b_1\"  class=\"iphorm_3_15_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_15 iphorm_3_15_1\" type=\"checkbox\" name=\"iphorm_3_15[]\" id=\"iphorm_3_15_6acc3aa33211b_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_15-input-li\" >\n                    <label for=\"iphorm_3_15_6acc3aa33211b_2\"  class=\"iphorm_3_15_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_15 iphorm_3_15_2\" type=\"checkbox\" name=\"iphorm_3_15[]\" id=\"iphorm_3_15_6acc3aa33211b_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_16-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_16-element-spacer\">\n        <label for=\"iphorm_3_16_6acc3aa33211b\" class=\"iphorm_3_16-outer-label\" >Your profession<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_16-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_16\" id=\"iphorm_3_16_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_16\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_17-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_17-element-spacer\">\n        <label for=\"iphorm_3_17_6acc3aa33211b\" class=\"iphorm_3_17-outer-label\" >Your hobbies:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_17-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_17\" id=\"iphorm_3_17_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_17\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_3_18-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_3_18-element-spacer\">\n        <label class=\"iphorm_3_18-outer-label\" >Marital status:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_3_18-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_3_18-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_18-input-li\" >\n                    <label for=\"iphorm_3_18_6acc3aa33211b_1\"  class=\"iphorm_3_18_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_18 iphorm_3_18_1\" type=\"checkbox\" name=\"iphorm_3_18[]\" id=\"iphorm_3_18_6acc3aa33211b_1\" value=\"Married\"  \/>\n                        Married                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_18-input-li\" >\n                    <label for=\"iphorm_3_18_6acc3aa33211b_2\"  class=\"iphorm_3_18_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_18 iphorm_3_18_2\" type=\"checkbox\" name=\"iphorm_3_18[]\" id=\"iphorm_3_18_6acc3aa33211b_2\" value=\"Single\"  \/>\n                        Single                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_18-input-li\" >\n                    <label for=\"iphorm_3_18_6acc3aa33211b_3\"  class=\"iphorm_3_18_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_18 iphorm_3_18_3\" type=\"checkbox\" name=\"iphorm_3_18[]\" id=\"iphorm_3_18_6acc3aa33211b_3\" value=\"Divorced\"  \/>\n                        Divorced                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_18-input-li\" >\n                    <label for=\"iphorm_3_18_6acc3aa33211b_4\"  class=\"iphorm_3_18_4_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_18 iphorm_3_18_4\" type=\"checkbox\" name=\"iphorm_3_18[]\" id=\"iphorm_3_18_6acc3aa33211b_4\" value=\"Widow(er)\"  \/>\n                        Widow(er)                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_3_19-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_3_19-element-spacer\">\n        <label class=\"iphorm_3_19-outer-label\" >Children<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_3_19-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_3_19-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_19-input-li\" >\n                    <label for=\"iphorm_3_19_6acc3aa33211b_1\"  class=\"iphorm_3_19_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_19 iphorm_3_19_1\" type=\"checkbox\" name=\"iphorm_3_19[]\" id=\"iphorm_3_19_6acc3aa33211b_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_19-input-li\" >\n                    <label for=\"iphorm_3_19_6acc3aa33211b_2\"  class=\"iphorm_3_19_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_19 iphorm_3_19_2\" type=\"checkbox\" name=\"iphorm_3_19[]\" id=\"iphorm_3_19_6acc3aa33211b_2\" value=\"None\"  \/>\n                        None                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_20-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_20-element-spacer\">\n        <label for=\"iphorm_3_20_6acc3aa33211b\" class=\"iphorm_3_20-outer-label\" >Number of children:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_20-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_20\" id=\"iphorm_3_20_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_20\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><strong>YOUR PARTNER\u2019S DATA:<\/strong><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_3_35-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_3_35-element-spacer\">\n        <label class=\"iphorm_3_35-outer-label\" >Sex:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_3_35-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_3_35-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_35-input-li\" >\n                    <label for=\"iphorm_3_35_6acc3aa33211b_1\"  class=\"iphorm_3_35_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_35 iphorm_3_35_1\" type=\"checkbox\" name=\"iphorm_3_35[]\" id=\"iphorm_3_35_6acc3aa33211b_1\" value=\"Male\"  \/>\n                        Male                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_35-input-li\" >\n                    <label for=\"iphorm_3_35_6acc3aa33211b_2\"  class=\"iphorm_3_35_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_35 iphorm_3_35_2\" type=\"checkbox\" name=\"iphorm_3_35[]\" id=\"iphorm_3_35_6acc3aa33211b_2\" value=\"Female\"  \/>\n                        Female                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-date iphorm_3_36-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\r\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-date iphorm_3_36-element-spacer\">\r\n        <label id=\"iphorm_3_36_6acc3aa33211b_date_label\" class=\"iphorm_3_36-outer-label\" >Date of birth:<\/label>        <div id=\"iphorm_3_36_6acc3aa33211b\" class=\"iphorm-input-wrap iphorm-input-wrap-date iphorm_3_36-input-wrap\" >\r\n        \t<div class=\"iphorm-clearfix\">\r\n                <div class=\"iphorm-input-wrap-date-select-wrap\">\r\n                                                                                <label id=\"iphorm_3_36_6acc3aa33211b_day_label\" class=\"iphorm-screen-reader-text\">Day<\/label>\r\n                    <select id=\"iphorm_3_36_6acc3aa33211b_day\" name=\"iphorm_3_36[day]\" class=\"iphorm_3_36-input-day\" aria-labelledby=\"iphorm_3_36_6acc3aa33211b_date_label iphorm_3_36_6acc3aa33211b_day_label\" >\r\n                        <option value=\"\">Day<\/option>                                                    <option value=\"1\" >1<\/option>\r\n                                                    <option value=\"2\" >2<\/option>\r\n                                                    <option value=\"3\" >3<\/option>\r\n                                                    <option value=\"4\" >4<\/option>\r\n                                                    <option value=\"5\" >5<\/option>\r\n                                                    <option value=\"6\" >6<\/option>\r\n                                                    <option value=\"7\" >7<\/option>\r\n                                                    <option value=\"8\" >8<\/option>\r\n                                                    <option value=\"9\" >9<\/option>\r\n                                                    <option value=\"10\" >10<\/option>\r\n                                                    <option value=\"11\" >11<\/option>\r\n                                                    <option value=\"12\" >12<\/option>\r\n                                                    <option value=\"13\" >13<\/option>\r\n                                                    <option value=\"14\" >14<\/option>\r\n                                                    <option value=\"15\" >15<\/option>\r\n                                                    <option value=\"16\" >16<\/option>\r\n                                                    <option value=\"17\" >17<\/option>\r\n                                                    <option value=\"18\" >18<\/option>\r\n                                                    <option value=\"19\" >19<\/option>\r\n                                                    <option value=\"20\" >20<\/option>\r\n                                                    <option value=\"21\" >21<\/option>\r\n                                                    <option value=\"22\" >22<\/option>\r\n                                                    <option value=\"23\" >23<\/option>\r\n                                                    <option value=\"24\" >24<\/option>\r\n                                                    <option value=\"25\" >25<\/option>\r\n                                                    <option value=\"26\" >26<\/option>\r\n                                                    <option value=\"27\" >27<\/option>\r\n                                                    <option value=\"28\" >28<\/option>\r\n                                                    <option value=\"29\" >29<\/option>\r\n                                                    <option value=\"30\" >30<\/option>\r\n                                                    <option value=\"31\" >31<\/option>\r\n                                            <\/select>\r\n                                        <label id=\"iphorm_3_36_6acc3aa33211b_month_label\" class=\"iphorm-screen-reader-text\">Month<\/label>\r\n                    <select id=\"iphorm_3_36_6acc3aa33211b_month\" name=\"iphorm_3_36[month]\" class=\"iphorm_3_36-input-month\" aria-labelledby=\"iphorm_3_36_6acc3aa33211b_date_label iphorm_3_36_6acc3aa33211b_month_label\" >\r\n                        <option value=\"\">Month<\/option>                                                    <option value=\"1\" >1<\/option>\r\n                                                    <option value=\"2\" >2<\/option>\r\n                                                    <option value=\"3\" >3<\/option>\r\n                                                    <option value=\"4\" >4<\/option>\r\n                                                    <option value=\"5\" >5<\/option>\r\n                                                    <option value=\"6\" >6<\/option>\r\n                                                    <option value=\"7\" >7<\/option>\r\n                                                    <option value=\"8\" >8<\/option>\r\n                                                    <option value=\"9\" >9<\/option>\r\n                                                    <option value=\"10\" >10<\/option>\r\n                                                    <option value=\"11\" >11<\/option>\r\n                                                    <option value=\"12\" >12<\/option>\r\n                                            <\/select>\r\n                                        <label id=\"iphorm_3_36_6acc3aa33211b_year_label\" class=\"iphorm-screen-reader-text\">Year<\/label>\r\n                    <select id=\"iphorm_3_36_6acc3aa33211b_year\" name=\"iphorm_3_36[year]\" class=\"iphorm_3_36-input-year\" aria-labelledby=\"iphorm_3_36_6acc3aa33211b_date_label iphorm_3_36_6acc3aa33211b_year_label\" >\r\n                        <option value=\"\">Year<\/option>                                                                                    <option value=\"2030\" >2030<\/option>\r\n                                                            <option value=\"2029\" >2029<\/option>\r\n                                                            <option value=\"2028\" >2028<\/option>\r\n                                                            <option value=\"2027\" >2027<\/option>\r\n                                                            <option value=\"2026\" >2026<\/option>\r\n                                                            <option value=\"2025\" >2025<\/option>\r\n                                                            <option value=\"2024\" >2024<\/option>\r\n                                                            <option value=\"2023\" >2023<\/option>\r\n                                                            <option value=\"2022\" >2022<\/option>\r\n                                                            <option value=\"2021\" >2021<\/option>\r\n                                                            <option value=\"2020\" >2020<\/option>\r\n                                                            <option value=\"2019\" >2019<\/option>\r\n                                                            <option value=\"2018\" >2018<\/option>\r\n                                                            <option value=\"2017\" >2017<\/option>\r\n                                                            <option value=\"2016\" >2016<\/option>\r\n                                                            <option value=\"2015\" >2015<\/option>\r\n                                                            <option value=\"2014\" >2014<\/option>\r\n                                                            <option value=\"2013\" >2013<\/option>\r\n                                                            <option value=\"2012\" >2012<\/option>\r\n                                                            <option value=\"2011\" >2011<\/option>\r\n                                                            <option value=\"2010\" >2010<\/option>\r\n                                                            <option value=\"2009\" >2009<\/option>\r\n                                                            <option value=\"2008\" >2008<\/option>\r\n                                                            <option value=\"2007\" >2007<\/option>\r\n                                                            <option value=\"2006\" >2006<\/option>\r\n                                                            <option value=\"2005\" >2005<\/option>\r\n                                                            <option value=\"2004\" >2004<\/option>\r\n                                                            <option value=\"2003\" >2003<\/option>\r\n                                                            <option value=\"2002\" >2002<\/option>\r\n                                                            <option value=\"2001\" >2001<\/option>\r\n                                                            <option value=\"2000\" >2000<\/option>\r\n                                                            <option value=\"1999\" >1999<\/option>\r\n                                                            <option value=\"1998\" >1998<\/option>\r\n                                                            <option value=\"1997\" >1997<\/option>\r\n                                                            <option value=\"1996\" >1996<\/option>\r\n                                                            <option value=\"1995\" >1995<\/option>\r\n                                                            <option value=\"1994\" >1994<\/option>\r\n                                                            <option value=\"1993\" >1993<\/option>\r\n                                                            <option value=\"1992\" >1992<\/option>\r\n                                                            <option value=\"1991\" >1991<\/option>\r\n                                                            <option value=\"1990\" >1990<\/option>\r\n                                                            <option value=\"1989\" >1989<\/option>\r\n                                                            <option value=\"1988\" >1988<\/option>\r\n                                                            <option value=\"1987\" >1987<\/option>\r\n                                                            <option value=\"1986\" >1986<\/option>\r\n                                                            <option value=\"1985\" >1985<\/option>\r\n                                                            <option value=\"1984\" >1984<\/option>\r\n                                                            <option value=\"1983\" >1983<\/option>\r\n                                                            <option value=\"1982\" >1982<\/option>\r\n                                                            <option value=\"1981\" >1981<\/option>\r\n                                                            <option value=\"1980\" >1980<\/option>\r\n                                                            <option value=\"1979\" >1979<\/option>\r\n                                                            <option value=\"1978\" >1978<\/option>\r\n                                                            <option value=\"1977\" >1977<\/option>\r\n                                                            <option value=\"1976\" >1976<\/option>\r\n                                                            <option value=\"1975\" >1975<\/option>\r\n                                                            <option value=\"1974\" >1974<\/option>\r\n                                                            <option value=\"1973\" >1973<\/option>\r\n                                                            <option value=\"1972\" >1972<\/option>\r\n                                                            <option value=\"1971\" >1971<\/option>\r\n                                                            <option value=\"1970\" >1970<\/option>\r\n                                                            <option value=\"1969\" >1969<\/option>\r\n                                                            <option value=\"1968\" >1968<\/option>\r\n                                                            <option value=\"1967\" >1967<\/option>\r\n                                                            <option value=\"1966\" >1966<\/option>\r\n                                                            <option value=\"1965\" >1965<\/option>\r\n                                                            <option value=\"1964\" >1964<\/option>\r\n                                                            <option value=\"1963\" >1963<\/option>\r\n                                                            <option value=\"1962\" >1962<\/option>\r\n                                                            <option value=\"1961\" >1961<\/option>\r\n                                                            <option value=\"1960\" >1960<\/option>\r\n                                                            <option value=\"1959\" >1959<\/option>\r\n                                                            <option value=\"1958\" >1958<\/option>\r\n                                                            <option value=\"1957\" >1957<\/option>\r\n                                                            <option value=\"1956\" >1956<\/option>\r\n                                                            <option value=\"1955\" >1955<\/option>\r\n                                                            <option value=\"1954\" >1954<\/option>\r\n                                                            <option value=\"1953\" >1953<\/option>\r\n                                                            <option value=\"1952\" >1952<\/option>\r\n                                                            <option value=\"1951\" >1951<\/option>\r\n                                                            <option value=\"1950\" >1950<\/option>\r\n                                                            <option value=\"1949\" >1949<\/option>\r\n                                                            <option value=\"1948\" >1948<\/option>\r\n                                                            <option value=\"1947\" >1947<\/option>\r\n                                                            <option value=\"1946\" >1946<\/option>\r\n                                                            <option value=\"1945\" >1945<\/option>\r\n                                                            <option value=\"1944\" >1944<\/option>\r\n                                                            <option value=\"1943\" >1943<\/option>\r\n                                                            <option value=\"1942\" >1942<\/option>\r\n                                                            <option value=\"1941\" >1941<\/option>\r\n                                                            <option value=\"1940\" >1940<\/option>\r\n                                                            <option value=\"1939\" >1939<\/option>\r\n                                                            <option value=\"1938\" >1938<\/option>\r\n                                                            <option value=\"1937\" >1937<\/option>\r\n                                                            <option value=\"1936\" >1936<\/option>\r\n                                                            <option value=\"1935\" >1935<\/option>\r\n                                                            <option value=\"1934\" >1934<\/option>\r\n                                                            <option value=\"1933\" >1933<\/option>\r\n                                                            <option value=\"1932\" >1932<\/option>\r\n                                                            <option value=\"1931\" >1931<\/option>\r\n                                                            <option value=\"1930\" >1930<\/option>\r\n                                                            <option value=\"1929\" >1929<\/option>\r\n                                                            <option value=\"1928\" >1928<\/option>\r\n                                                            <option value=\"1927\" >1927<\/option>\r\n                                                            <option value=\"1926\" >1926<\/option>\r\n                                                            <option value=\"1925\" >1925<\/option>\r\n                                                            <option value=\"1924\" >1924<\/option>\r\n                                                            <option value=\"1923\" >1923<\/option>\r\n                                                            <option value=\"1922\" >1922<\/option>\r\n                                                            <option value=\"1921\" >1921<\/option>\r\n                                                            <option value=\"1920\" >1920<\/option>\r\n                                                            <option value=\"1919\" >1919<\/option>\r\n                                                            <option value=\"1918\" >1918<\/option>\r\n                                                            <option value=\"1917\" >1917<\/option>\r\n                                                            <option value=\"1916\" >1916<\/option>\r\n                                                            <option value=\"1915\" >1915<\/option>\r\n                                                            <option value=\"1914\" >1914<\/option>\r\n                                                            <option value=\"1913\" >1913<\/option>\r\n                                                            <option value=\"1912\" >1912<\/option>\r\n                                                            <option value=\"1911\" >1911<\/option>\r\n                                                            <option value=\"1910\" >1910<\/option>\r\n                                                            <option value=\"1909\" >1909<\/option>\r\n                                                            <option value=\"1908\" >1908<\/option>\r\n                                                            <option value=\"1907\" >1907<\/option>\r\n                                                            <option value=\"1906\" >1906<\/option>\r\n                                                            <option value=\"1905\" >1905<\/option>\r\n                                                            <option value=\"1904\" >1904<\/option>\r\n                                                            <option value=\"1903\" >1903<\/option>\r\n                                                            <option value=\"1902\" >1902<\/option>\r\n                                                            <option value=\"1901\" >1901<\/option>\r\n                                                            <option value=\"1900\" >1900<\/option>\r\n                                                                        <\/select>\r\n                <\/div>\r\n                            <\/div>\r\n                    <\/div>\r\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\r\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-time iphorm_3_37-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-time iphorm_3_37-element-spacer\">\n        <label id=\"iphorm_3_37_6acc3aa33211b_time_label\" class=\"iphorm_3_37-outer-label\" >Exact time of birth:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-date iphorm_3_37-input-wrap\" >\n            <label id=\"iphorm_3_37_6acc3aa33211b_hour_label\" class=\"iphorm-screen-reader-text\">Hour<\/label>\n            <select id=\"iphorm_3_37_6acc3aa33211b_hour\"  name=\"iphorm_3_37[hour]\" class=\"iphorm_3_37-input-hour\" aria-labelledby=\"iphorm_3_37_6acc3aa33211b_time_label iphorm_3_37_6acc3aa33211b_hour_label\" >\n                <option value=\"\">HH<\/option>                                                                                    <option value=\"00\" >00<\/option>\n                                                                    <option value=\"01\" >01<\/option>\n                                                                    <option value=\"02\" >02<\/option>\n                                                                    <option value=\"03\" >03<\/option>\n                                                                    <option value=\"04\" >04<\/option>\n                                                                    <option value=\"05\" >05<\/option>\n                                                                    <option value=\"06\" >06<\/option>\n                                                                    <option value=\"07\" >07<\/option>\n                                                                    <option value=\"08\" >08<\/option>\n                                                                    <option value=\"09\" >09<\/option>\n                                                                    <option value=\"10\" >10<\/option>\n                                                                    <option value=\"11\" >11<\/option>\n                                                                    <option value=\"12\"  selected='selected'>12<\/option>\n                                                                    <option value=\"13\" >13<\/option>\n                                                                    <option value=\"14\" >14<\/option>\n                                                                    <option value=\"15\" >15<\/option>\n                                                                    <option value=\"16\" >16<\/option>\n                                                                    <option value=\"17\" >17<\/option>\n                                                                    <option value=\"18\" >18<\/option>\n                                                                    <option value=\"19\" >19<\/option>\n                                                                    <option value=\"20\" >20<\/option>\n                                                                    <option value=\"21\" >21<\/option>\n                                                                    <option value=\"22\" >22<\/option>\n                                                                    <option value=\"23\" >23<\/option>\n                                                <\/select>\n            <label id=\"iphorm_3_37_6acc3aa33211b_minute_label\" class=\"iphorm-screen-reader-text\">Minute<\/label>\n            <select id=\"iphorm_3_37_6acc3aa33211b_minute\" name=\"iphorm_3_37[minute]\" class=\"iphorm_3_37-input-minute\" aria-labelledby=\"iphorm_3_37_6acc3aa33211b_time_label iphorm_3_37_6acc3aa33211b_minute_label\" >\n                <option value=\"\">MM<\/option>                                                                                    <option value=\"00\"  selected='selected'>00<\/option>\n                                                                                                        <option value=\"01\" >01<\/option>\n                                                                                                        <option value=\"02\" >02<\/option>\n                                                                                                        <option value=\"03\" >03<\/option>\n                                                                                                        <option value=\"04\" >04<\/option>\n                                                                                                        <option value=\"05\" >05<\/option>\n                                                                                                        <option value=\"06\" >06<\/option>\n                                                                                                        <option value=\"07\" >07<\/option>\n                                                                                                        <option value=\"08\" >08<\/option>\n                                                                                                        <option value=\"09\" >09<\/option>\n                                                                                                        <option value=\"10\" >10<\/option>\n                                                                                                        <option value=\"11\" >11<\/option>\n                                                                                                        <option value=\"12\" >12<\/option>\n                                                                                                        <option value=\"13\" >13<\/option>\n                                                                                                        <option value=\"14\" >14<\/option>\n                                                                                                        <option value=\"15\" >15<\/option>\n                                                                                                        <option value=\"16\" >16<\/option>\n                                                                                                        <option value=\"17\" >17<\/option>\n                                                                                                        <option value=\"18\" >18<\/option>\n                                                                                                        <option value=\"19\" >19<\/option>\n                                                                                                        <option value=\"20\" >20<\/option>\n                                                                                                        <option value=\"21\" >21<\/option>\n                                                                                                        <option value=\"22\" >22<\/option>\n                                                                                                        <option value=\"23\" >23<\/option>\n                                                                                                        <option value=\"24\" >24<\/option>\n                                                                                                        <option value=\"25\" >25<\/option>\n                                                                                                        <option value=\"26\" >26<\/option>\n                                                                                                        <option value=\"27\" >27<\/option>\n                                                                                                        <option value=\"28\" >28<\/option>\n                                                                                                        <option value=\"29\" >29<\/option>\n                                                                                                        <option value=\"30\" >30<\/option>\n                                                                                                        <option value=\"31\" >31<\/option>\n                                                                                                        <option value=\"32\" >32<\/option>\n                                                                                                        <option value=\"33\" >33<\/option>\n                                                                                                        <option value=\"34\" >34<\/option>\n                                                                                                        <option value=\"35\" >35<\/option>\n                                                                                                        <option value=\"36\" >36<\/option>\n                                                                                                        <option value=\"37\" >37<\/option>\n                                                                                                        <option value=\"38\" >38<\/option>\n                                                                                                        <option value=\"39\" >39<\/option>\n                                                                                                        <option value=\"40\" >40<\/option>\n                                                                                                        <option value=\"41\" >41<\/option>\n                                                                                                        <option value=\"42\" >42<\/option>\n                                                                                                        <option value=\"43\" >43<\/option>\n                                                                                                        <option value=\"44\" >44<\/option>\n                                                                                                        <option value=\"45\" >45<\/option>\n                                                                                                        <option value=\"46\" >46<\/option>\n                                                                                                        <option value=\"47\" >47<\/option>\n                                                                                                        <option value=\"48\" >48<\/option>\n                                                                                                        <option value=\"49\" >49<\/option>\n                                                                                                        <option value=\"50\" >50<\/option>\n                                                                                                        <option value=\"51\" >51<\/option>\n                                                                                                        <option value=\"52\" >52<\/option>\n                                                                                                        <option value=\"53\" >53<\/option>\n                                                                                                        <option value=\"54\" >54<\/option>\n                                                                                                        <option value=\"55\" >55<\/option>\n                                                                                                        <option value=\"56\" >56<\/option>\n                                                                                                        <option value=\"57\" >57<\/option>\n                                                                                                        <option value=\"58\" >58<\/option>\n                                                                                                        <option value=\"59\" >59<\/option>\n                                                <\/select>\n                            <input type=\"hidden\" name=\"iphorm_3_37[ampm]\" value=\"\" \/>\n                                <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_3_38-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_3_38-element-spacer\">\n        <label class=\"iphorm_3_38-outer-label\" >If you don\u2019t know the exact time of birth, enter the approximate time and tick this box:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_3_38-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_3_38-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_38-input-li\" >\n                    <label for=\"iphorm_3_38_6acc3aa33211b_1\"  class=\"iphorm_3_38_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_38 iphorm_3_38_1\" type=\"checkbox\" name=\"iphorm_3_38[]\" id=\"iphorm_3_38_6acc3aa33211b_1\" value=\"I know the approximate time of birth only.\"  \/>\n                        I know the approximate time of birth only.                    <\/label>\n                <\/div>\n                        <\/div>\n                <p class=\"iphorm-description\" >Attention! If you don\u2019t know the exact time of birth, predictions may be inaccurate. The approximate time of birth can be stated for psychological and compatibility horoscopes.<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-textarea iphorm_3_21-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-textarea iphorm_3_21-element-spacer\">\n        <label for=\"iphorm_3_21_6acc3aa33211b\" class=\"iphorm_3_21-outer-label\" >You can write down the specific issues you are interested in or what specifically the astrologer should take into account when analyzing the Horoscope:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-textarea iphorm_3_21-input-wrap\" >\n            <textarea class=\"iphorm-element-textarea  iphorm_3_21\" id=\"iphorm_3_21_6acc3aa33211b\" name=\"iphorm_3_21\"   rows=\"5\" cols=\"25\"><\/textarea>\n                <p class=\"iphorm-description\" >The clearer and more specific you formulate the questions and issues you are interested in, the more accurately we will be able to present information to you on the basis of your horoscope.<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_39-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_39-element-spacer\">\n        <label for=\"iphorm_3_39_6acc3aa33211b\" class=\"iphorm_3_39-outer-label\" >Exact country of birth:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_39-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_39\" id=\"iphorm_3_39_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_39\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_40-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_40-element-spacer\">\n        <label for=\"iphorm_3_40_6acc3aa33211b\" class=\"iphorm_3_40-outer-label\" >Exact city of birth:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_40-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_40\" id=\"iphorm_3_40_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_40\"  value=\"\"  \/>\n                <p class=\"iphorm-description\" >(If your partner was born in a small settlement, state the closest city.)<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_41-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_41-element-spacer\">\n        <label for=\"iphorm_3_41_6acc3aa33211b\" class=\"iphorm_3_41-outer-label\" >Country where your partner lives in now:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_41-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_41\" id=\"iphorm_3_41_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_41\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_42-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_42-element-spacer\">\n        <label for=\"iphorm_3_42_6acc3aa33211b\" class=\"iphorm_3_42-outer-label\" >City where your partner lives in now:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_42-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_42\" id=\"iphorm_3_42_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_42\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_3_43-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_3_43-element-spacer\">\n        <label class=\"iphorm_3_43-outer-label\" >Is your partner employed at the moment?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_3_43-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_3_43-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_43-input-li\" >\n                    <label for=\"iphorm_3_43_6acc3aa33211b_1\"  class=\"iphorm_3_43_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_43 iphorm_3_43_1\" type=\"checkbox\" name=\"iphorm_3_43[]\" id=\"iphorm_3_43_6acc3aa33211b_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_43-input-li\" >\n                    <label for=\"iphorm_3_43_6acc3aa33211b_2\"  class=\"iphorm_3_43_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_43 iphorm_3_43_2\" type=\"checkbox\" name=\"iphorm_3_43[]\" id=\"iphorm_3_43_6acc3aa33211b_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_44-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_44-element-spacer\">\n        <label for=\"iphorm_3_44_6acc3aa33211b\" class=\"iphorm_3_44-outer-label\" >Enter your partner\u2019s profession<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_44-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_44\" id=\"iphorm_3_44_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_44\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_45-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_45-element-spacer\">\n        <label for=\"iphorm_3_45_6acc3aa33211b\" class=\"iphorm_3_45-outer-label\" >Your partner\u2019s hobbies:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_45-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_45\" id=\"iphorm_3_45_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_45\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_3_46-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_3_46-element-spacer\">\n        <label class=\"iphorm_3_46-outer-label\" >Your partner\u2019s education:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_3_46-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_3_46-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_46-input-li\" >\n                    <label for=\"iphorm_3_46_6acc3aa33211b_1\"  class=\"iphorm_3_46_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_46 iphorm_3_46_1\" type=\"checkbox\" name=\"iphorm_3_46[]\" id=\"iphorm_3_46_6acc3aa33211b_1\" value=\"Secondary\"  \/>\n                        Secondary                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_46-input-li\" >\n                    <label for=\"iphorm_3_46_6acc3aa33211b_2\"  class=\"iphorm_3_46_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_46 iphorm_3_46_2\" type=\"checkbox\" name=\"iphorm_3_46[]\" id=\"iphorm_3_46_6acc3aa33211b_2\" value=\"Secondary-special\"  \/>\n                        Secondary-special                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_46-input-li\" >\n                    <label for=\"iphorm_3_46_6acc3aa33211b_3\"  class=\"iphorm_3_46_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_46 iphorm_3_46_3\" type=\"checkbox\" name=\"iphorm_3_46[]\" id=\"iphorm_3_46_6acc3aa33211b_3\" value=\"Higher\"  \/>\n                        Higher                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_47-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_47-element-spacer\">\n        <label for=\"iphorm_3_47_6acc3aa33211b\" class=\"iphorm_3_47-outer-label\" >State your partner\u2019s speciality:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_47-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_47\" id=\"iphorm_3_47_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_47\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_3_48-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_3_48-element-spacer\">\n        <label class=\"iphorm_3_48-outer-label\" >Your partner\u2019s marital status:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_3_48-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_3_48-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_48-input-li\" >\n                    <label for=\"iphorm_3_48_6acc3aa33211b_1\"  class=\"iphorm_3_48_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_48 iphorm_3_48_1\" type=\"checkbox\" name=\"iphorm_3_48[]\" id=\"iphorm_3_48_6acc3aa33211b_1\" value=\"Married\"  \/>\n                        Married                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_48-input-li\" >\n                    <label for=\"iphorm_3_48_6acc3aa33211b_2\"  class=\"iphorm_3_48_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_48 iphorm_3_48_2\" type=\"checkbox\" name=\"iphorm_3_48[]\" id=\"iphorm_3_48_6acc3aa33211b_2\" value=\"Single\"  \/>\n                        Single                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_48-input-li\" >\n                    <label for=\"iphorm_3_48_6acc3aa33211b_3\"  class=\"iphorm_3_48_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_48 iphorm_3_48_3\" type=\"checkbox\" name=\"iphorm_3_48[]\" id=\"iphorm_3_48_6acc3aa33211b_3\" value=\"Divorced\"  \/>\n                        Divorced                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_48-input-li\" >\n                    <label for=\"iphorm_3_48_6acc3aa33211b_4\"  class=\"iphorm_3_48_4_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_48 iphorm_3_48_4\" type=\"checkbox\" name=\"iphorm_3_48[]\" id=\"iphorm_3_48_6acc3aa33211b_4\" value=\"Widow(er)\"  \/>\n                        Widow(er)                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_3_49-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_3_49-element-spacer\">\n        <label class=\"iphorm_3_49-outer-label\" >Your partner\u2019s children<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_3_49-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_3_49-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_49-input-li\" >\n                    <label for=\"iphorm_3_49_6acc3aa33211b_1\"  class=\"iphorm_3_49_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_49 iphorm_3_49_1\" type=\"checkbox\" name=\"iphorm_3_49[]\" id=\"iphorm_3_49_6acc3aa33211b_1\" value=\"None\"  \/>\n                        None                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_49-input-li\" >\n                    <label for=\"iphorm_3_49_6acc3aa33211b_2\"  class=\"iphorm_3_49_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_49 iphorm_3_49_2\" type=\"checkbox\" name=\"iphorm_3_49[]\" id=\"iphorm_3_49_6acc3aa33211b_2\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_50-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_50-element-spacer\">\n        <label for=\"iphorm_3_50_6acc3aa33211b\" class=\"iphorm_3_50-outer-label\" >Number of children<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_50-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_50\" id=\"iphorm_3_50_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_50\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_3_22-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_3_22-element-spacer\">\n        <label class=\"iphorm_3_22-outer-label\" >May we contact you should the astrologer have any questions regarding more specific data?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_3_22-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_3_22-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_22-input-li\" >\n                    <label for=\"iphorm_3_22_6acc3aa33211b_1\"  class=\"iphorm_3_22_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_22 iphorm_3_22_1\" type=\"checkbox\" name=\"iphorm_3_22[]\" id=\"iphorm_3_22_6acc3aa33211b_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_22-input-li\" >\n                    <label for=\"iphorm_3_22_6acc3aa33211b_2\"  class=\"iphorm_3_22_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_22 iphorm_3_22_2\" type=\"checkbox\" name=\"iphorm_3_22[]\" id=\"iphorm_3_22_6acc3aa33211b_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_23-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_23-element-spacer\">\n        <label for=\"iphorm_3_23_6acc3aa33211b\" class=\"iphorm_3_23-outer-label\" >Telephone number:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_23-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_23\" id=\"iphorm_3_23_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_23\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_24-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_24-element-spacer\">\n        <label for=\"iphorm_3_24_6acc3aa33211b\" class=\"iphorm_3_24-outer-label\" >E-mail:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_24-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_24\" id=\"iphorm_3_24_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_24\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_3_25-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_3_25-element-spacer\">\n        <label class=\"iphorm_3_25-outer-label\" >Please state in which way you wish to receive the Horoscope you have ordered in a written form:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_3_25-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_3_25-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_25-input-li\" >\n                    <label for=\"iphorm_3_25_6acc3aa33211b_1\"  class=\"iphorm_3_25_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_25 iphorm_3_25_1\" type=\"checkbox\" name=\"iphorm_3_25[]\" id=\"iphorm_3_25_6acc3aa33211b_1\" value=\"By e-mail\"  \/>\n                        By e-mail                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_25-input-li\" >\n                    <label for=\"iphorm_3_25_6acc3aa33211b_2\"  class=\"iphorm_3_25_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_25 iphorm_3_25_2\" type=\"checkbox\" name=\"iphorm_3_25[]\" id=\"iphorm_3_25_6acc3aa33211b_2\" value=\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"  \/>\n                        By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_26-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_26-element-spacer\">\n        <label for=\"iphorm_3_26_6acc3aa33211b\" class=\"iphorm_3_26-outer-label\" >State e-mail address at which you wish to receive the horoscope in a written form:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_26-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_26\" id=\"iphorm_3_26_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_26\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-html iphorm_3_28-element-wrap iphorm-clearfix\">\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-html iphorm_3_28-element-spacer\">\n        Please state your exact address at which we could send the Horoscope:    <\/div>\n<\/div>\n<div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_27-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_27-element-spacer\">\n        <label for=\"iphorm_3_27_6acc3aa33211b\" class=\"iphorm_3_27-outer-label\" >Country:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_27-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_27\" id=\"iphorm_3_27_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_27\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_29-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_29-element-spacer\">\n        <label for=\"iphorm_3_29_6acc3aa33211b\" class=\"iphorm_3_29-outer-label\" >City:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_29-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_29\" id=\"iphorm_3_29_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_29\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_30-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_30-element-spacer\">\n        <label for=\"iphorm_3_30_6acc3aa33211b\" class=\"iphorm_3_30-outer-label\" >Street:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_30-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_30\" id=\"iphorm_3_30_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_30\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_31-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_31-element-spacer\">\n        <label for=\"iphorm_3_31_6acc3aa33211b\" class=\"iphorm_3_31-outer-label\" >House:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_31-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_31\" id=\"iphorm_3_31_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_31\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_3_32-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_3_32-element-spacer\">\n        <label for=\"iphorm_3_32_6acc3aa33211b\" class=\"iphorm_3_32-outer-label\" >Apartment:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_3_32-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_3_32\" id=\"iphorm_3_32_6acc3aa33211b\" type=\"text\" name=\"iphorm_3_32\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_3_33-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_3_33-element-spacer\">\n        <label class=\"iphorm_3_33-outer-label\" >Order confirmation:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_3_33-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_3_33-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_3_33-input-li\" >\n                    <label for=\"iphorm_3_33_6acc3aa33211b_1\"  class=\"iphorm_3_33_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_3_33 iphorm_3_33_1\" type=\"checkbox\" name=\"iphorm_3_33[]\" id=\"iphorm_3_33_6acc3aa33211b_1\" value=\"I order a horoscope and guarantee that the data presented in the registration form is true. I undertake to effect a transfer of money in the bank for my order within 5 business days.\"  \/>\n                        I order a horoscope and guarantee that the data presented in the registration form is true. I undertake to effect a transfer of money in the bank for my order within 5 business days.                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-recaptcha g-recaptcha-response-element-wrap iphorm_3_53-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-required\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-captcha g-recaptcha-response-element-spacer\">\n        <label class=\"g-recaptcha-response-outer-label\" >Type the words<span class=\"iphorm-required\">(required)<\/span><\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-recaptcha g-recaptcha-response-input-wrap\" >\n                            <div id=\"iphorm_3_53_6acc3aa33211b\" class=\"iphorm-recaptcha\" data-unique-id=\"iphorm_3_53_6acc3aa33211b\" data-config=\"{&quot;sitekey&quot;:&quot;6LedJT8UAAAAAF98QMjpclkDUi0x8zoTC2M7u2VB&quot;,&quot;theme&quot;:&quot;light&quot;,&quot;type&quot;:&quot;image&quot;,&quot;size&quot;:&quot;normal&quot;}\"><\/div>\n                <noscript>\n                  <div style=\"width: 302px; height: 352px;\">\n                    <div style=\"width: 302px; height: 352px; position: relative;\">\n                      <div style=\"width: 302px; height: 352px; position: absolute;\">\n                        <iframe src=\"https:\/\/www.google.com\/recaptcha\/api\/fallback?k=6LedJT8UAAAAAF98QMjpclkDUi0x8zoTC2M7u2VB\"\n                                frameborder=\"0\" scrolling=\"no\"\n                                style=\"width: 302px; height:352px; border-style: none;\">\n                        <\/iframe>\n                      <\/div>\n                      <div style=\"width: 250px; height: 80px; position: absolute; border-style: none;\n                                  bottom: 21px; left: 25px; margin: 0px; padding: 0px; right: 25px;\">\n                        <textarea name=\"g-recaptcha-response\" class=\"g-recaptcha-response\"\n                                  style=\"width: 250px; height: 80px; border: 1px solid #c1c1c1;\n                                         margin: 0px; padding: 0px; resize: none;\"><\/textarea>\n                      <\/div>\n                    <\/div>\n                  <\/div>\n                <\/noscript>\n                                <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-hidden\">\n    <label>This field should be left blank<input type=\"text\" name=\"iphorm_3_0\" \/><\/label>\n<\/div>                <div class=\"iphorm-submit-wrap iphorm-submit-wrap-3 iphorm-clearfix\" >\n                    <div class=\"iphorm-submit-input-wrap iphorm-submit-input-wrap-3\" >\n                        <button class=\"iphorm-submit-element\" type=\"submit\" name=\"iphorm_submit\" ><span ><em >ORDER<\/em><\/span><\/button>\n                    <\/div>\n                    <div class=\"iphorm-loading-wrap\"><span class=\"iphorm-loading\">Please wait...<\/span><\/div>\n                <\/div>\n            <\/div>\n                                                                        <div class=\"iphorm-success-message iphorm-hidden\" ><\/div>\n                                    <\/div>\n            <\/form>\n    <script type=\"text\/javascript\">\n    jQuery('#iphorm-outer-6acc3aa33211b script').remove();\n    <\/script>\n<\/div>\t<\/div>\r\n\r\n\t<div class=\"hidden-form form-VH\">\r\n\t<div id=\"iphorm-outer-6acc3aa335143\" class=\"iphorm-outer iphorm-outer-4 iphorm-uniform-theme-default iphorm-theme-light-light iphorm-has-logic\" >\n    <script type=\"text\/javascript\">\n        jQuery(document).ready(function($) {\n                            iPhorm.logic[4] = {\"logic\":{\"36\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"35\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"42\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"41\",\"operator\":\"eq\",\"value\":\"No\"}]},\"39\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"38\",\"operator\":\"eq\",\"value\":\"Other\"}]},\"23\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"22\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"24\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"22\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"26\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By e-mail\"}]},\"28\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"27\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"29\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"30\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"31\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"32\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]}},\"dependents\":{\"35\":[36],\"41\":[42],\"38\":[39],\"22\":[23,24],\"25\":[26,28,27,29,30,31,32]},\"animate\":true};\n                        $('#iphorm-6acc3aa335143').iPhorm({\"id\":4,\"uniqueId\":\"6acc3aa335143\",\"useAjax\":true,\"successMessageTimeout\":160,\"resetFormValues\":\"\",\"clElementIds\":[36,42,39,23,24,26,28,27,29,30,31,32],\"clDependentElementIds\":[35,41,38,22,25],\"centerFancybox\":true,\"centerFancyboxSpeed\":true});\n                        if ($.isFunction($.fn.qtip)) {\n                $('.iphorm-tooltip-hover', iPhorm.instance.$form).qtip({\n                    style: {\n                        classes: 'qtip-plain qtip-shadow'\n                    },\n                    position: {\n                        my: 'left center',\n                        at: 'right center',\n                        viewport: $(window),\n                        adjust: {\n                            method: 'shift'\n                        }\n                    }\n                });\n                $('.iphorm-tooltip-click', iPhorm.instance.$form).qtip({\n                    style: {\n                        classes: 'qtip-plain qtip-shadow'\n                    },\n                    position: {\n                        my: 'left center',\n                        at: 'right center',\n                        viewport: $(window),\n                        adjust: {\n                            method: 'shift'\n                        }\n                    },\n                    show: {\n                        event: 'focus'\n                    },\n                    hide: {\n                        event: 'unfocus'\n                    }\n                });\n                $('.iphorm-tooltip-icon-hover', iPhorm.instance.$form).qtip({\n                    style: {\n                        classes: 'qtip-plain qtip-shadow'\n                    },\n                    position: {\n                        my: 'left center',\n                        at: 'right center',\n                        viewport: $(window),\n                        adjust: {\n                            method: 'shift'\n                        }\n                    },\n                    content: {\n                        text: function (api) {\n                            return $(this).find('.iphorm-tooltip-icon-content').html();\n                        }\n                    }\n                });\n                $('.iphorm-tooltip-icon-click', iPhorm.instance.$form).qtip({\n                    style: {\n                        classes: 'qtip-plain qtip-shadow'\n                    },\n                    position: {\n                        my: 'left center',\n                        at: 'right center',\n                        viewport: $(window),\n                        adjust: {\n                            method: 'shift'\n                        }\n                    },\n                    show: {\n                        event: 'click'\n                    },\n                    hide: {\n                        event: 'unfocus'\n                    },\n                    content: {\n                        text: function (api) {\n                            return $(this).find('.iphorm-tooltip-icon-content').html();\n                        }\n                    }\n                });\n                $('.iphorm-labels-inside > .iphorm-element-spacer > label').hover(function () {\n                    $(this).siblings('.iphorm-input-wrap').find('.iphorm-tooltip-hover').qtip('show');\n                }, function () {\n                    $(this).siblings('.iphorm-input-wrap').find('.iphorm-tooltip-hover').qtip('hide');\n                });\n            }\n                                    if ($.isFunction($.fn.uniform)) {\n                $('select, input:checkbox, input:radio', iPhorm.instance.$form).uniform({context: iPhorm.instance.$form, selectAutoWidth: false});\n            }\n                        if ($.isFunction($.fn.inFieldLabels)) {\n                $('.iphorm-labels-inside:not(.iphorm-element-wrap-recaptcha) > .iphorm-element-spacer > label', iPhorm.instance.$form).inFieldLabels();\n            }\n                        $('.iphorm-group-row > div:last-child:not(:first-child)', iPhorm.instance.$form).add('.iphorm-group-row:last-child', iPhorm.instance.$form).addClass('last-child');\n                            iPhorm.instance.applyAllLogic(true);\n                $('#iphorm-outer-6acc3aa335143').css('visibility', 'visible');\n                    });\n    <\/script>\n    <form id=\"iphorm-6acc3aa335143\" class=\"iphorm iphorm-form-4\" action=\"\/en\/wp-json\/wp\/v2\/pages\/40#iphorm-6acc3aa335143\" method=\"post\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\">\n        <div class=\"iphorm-inner iphorm-inner-4\" >\n            <input type=\"hidden\" name=\"iphorm_id\" value=\"4\" \/>\n            <input type=\"hidden\" name=\"iphorm_uid\" value=\"6acc3aa335143\" \/>\n            <input type=\"hidden\" name=\"form_url\" value=\"http:\/\/www.e-astrology.eu\/en\/wp-json\/wp\/v2\/pages\/40\" \/>\n            <input type=\"hidden\" name=\"referring_url\" value=\"\" \/>\n            <input type=\"hidden\" name=\"post_id\" value=\"\" \/>\n            <input type=\"hidden\" name=\"post_title\" value=\"\" \/>\n                            <h3 class=\"iphorm-title\" >CHILDREN\u2019S HOROSCOPE \u2013 ORDER FORM<\/h3>\n                                                <div class=\"iphorm-elements iphorm-elements-4 iphorm-clearfix\" >\n                Attention! Please complete all boxes of the questionnaire very carefully. The Centre guarantees that all information stated in the registration form and information concerning your horoscope is confidential and it shall not be disclosed to any third parties in any case.\n<br><\/br><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_4_46-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_4_46-element-spacer\">\n        <label class=\"iphorm_4_46-outer-label\" >Type (kind) of ORAL consultation:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_4_46-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_4_46-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_46-input-li\" >\n                    <label for=\"iphorm_4_46_6acc3aa335143_1\"  class=\"iphorm_4_46_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_46 iphorm_4_46_1\" type=\"checkbox\" name=\"iphorm_4_46[]\" id=\"iphorm_4_46_6acc3aa335143_1\" value=\"Consultation on SKYPE (cost 50 eur)\"  \/>\n                        Consultation on SKYPE (cost 50 eur)                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_46-input-li\" >\n                    <label for=\"iphorm_4_46_6acc3aa335143_2\"  class=\"iphorm_4_46_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_46 iphorm_4_46_2\" type=\"checkbox\" name=\"iphorm_4_46[]\" id=\"iphorm_4_46_6acc3aa335143_2\" value=\"Personal visit\/meeting (only in Vilnius, Lithuania)\"  \/>\n                        Personal visit\/meeting (only in Vilnius, Lithuania)                    <\/label>\n                <\/div>\n                        <\/div>\n                <p class=\"iphorm-description\" >Attention! The cost of personal consultation (meeting with the astrologer) is determined individually.<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_4_47-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_4_47-element-spacer\">\n        <label class=\"iphorm_4_47-outer-label\" >Order of the Horoscope in a written form:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_4_47-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_4_47-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_47-input-li\" >\n                    <label for=\"iphorm_4_47_6acc3aa335143_1\"  class=\"iphorm_4_47_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_47 iphorm_4_47_1\" type=\"checkbox\" name=\"iphorm_4_47[]\" id=\"iphorm_4_47_6acc3aa335143_1\" value=\"I want to order the Horoscope in a WRITTEN form\"  \/>\n                        I want to order the Horoscope in a WRITTEN form                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_4_40-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_4_40-element-spacer\">\n        <label class=\"iphorm_4_40-outer-label\" >I want to order the horoscope:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_4_40-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_4_40-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_40-input-li\" >\n                    <label for=\"iphorm_4_40_6acc3aa335143_1\"  class=\"iphorm_4_40_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_40 iphorm_4_40_1\" type=\"checkbox\" name=\"iphorm_4_40[]\" id=\"iphorm_4_40_6acc3aa335143_1\" value=\"in English Language \u2013 120 eur\"  \/>\n                        in English Language \u2013 120 eur                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_40-input-li\" >\n                    <label for=\"iphorm_4_40_6acc3aa335143_2\"  class=\"iphorm_4_40_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_40 iphorm_4_40_2\" type=\"checkbox\" name=\"iphorm_4_40[]\" id=\"iphorm_4_40_6acc3aa335143_2\" value=\"in Russian Language \u2013 60 eur\"  \/>\n                        in Russian Language \u2013 60 eur                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_40-input-li\" >\n                    <label for=\"iphorm_4_40_6acc3aa335143_3\"  class=\"iphorm_4_40_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_40 iphorm_4_40_3\" type=\"checkbox\" name=\"iphorm_4_40[]\" id=\"iphorm_4_40_6acc3aa335143_3\" value=\"in Lithuanian Language \u2013 120 eur\"  \/>\n                        in Lithuanian Language \u2013 120 eur                    <\/label>\n                <\/div>\n                        <\/div>\n                <p class=\"iphorm-description\" >The cost of a written horoscope depends on the chosen language<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_4_2-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_4_2-element-spacer\">\n        <label for=\"iphorm_4_2_6acc3aa335143\" class=\"iphorm_4_2-outer-label\" >Name and surname:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_4_2-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_4_2\" id=\"iphorm_4_2_6acc3aa335143\" type=\"text\" name=\"iphorm_4_2\"  value=\"\"  \/>\n                <p class=\"iphorm-description\" >* We need your name and surname to check and receive the bank transfer (payment of your order).<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_4_34-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_4_34-element-spacer\">\n        <label for=\"iphorm_4_34_6acc3aa335143\" class=\"iphorm_4_34-outer-label\" >Your child\u2019s name:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_4_34-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_4_34\" id=\"iphorm_4_34_6acc3aa335143\" type=\"text\" name=\"iphorm_4_34\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_4_3-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_4_3-element-spacer\">\n        <label class=\"iphorm_4_3-outer-label\" >Sex:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_4_3-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_4_3-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_3-input-li\" >\n                    <label for=\"iphorm_4_3_6acc3aa335143_1\"  class=\"iphorm_4_3_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_3 iphorm_4_3_1\" type=\"checkbox\" name=\"iphorm_4_3[]\" id=\"iphorm_4_3_6acc3aa335143_1\" value=\"Male\"  \/>\n                        Male                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_3-input-li\" >\n                    <label for=\"iphorm_4_3_6acc3aa335143_2\"  class=\"iphorm_4_3_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_3 iphorm_4_3_2\" type=\"checkbox\" name=\"iphorm_4_3[]\" id=\"iphorm_4_3_6acc3aa335143_2\" value=\"Female\"  \/>\n                        Female                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-date iphorm_4_4-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\r\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-date iphorm_4_4-element-spacer\">\r\n        <label id=\"iphorm_4_4_6acc3aa335143_date_label\" class=\"iphorm_4_4-outer-label\" >Date of birth:<\/label>        <div id=\"iphorm_4_4_6acc3aa335143\" class=\"iphorm-input-wrap iphorm-input-wrap-date iphorm_4_4-input-wrap\" >\r\n        \t<div class=\"iphorm-clearfix\">\r\n                <div class=\"iphorm-input-wrap-date-select-wrap\">\r\n                                                                                <label id=\"iphorm_4_4_6acc3aa335143_day_label\" class=\"iphorm-screen-reader-text\">Day<\/label>\r\n                    <select id=\"iphorm_4_4_6acc3aa335143_day\" name=\"iphorm_4_4[day]\" class=\"iphorm_4_4-input-day\" aria-labelledby=\"iphorm_4_4_6acc3aa335143_date_label iphorm_4_4_6acc3aa335143_day_label\" >\r\n                        <option value=\"\">Day<\/option>                                                    <option value=\"1\" >1<\/option>\r\n                                                    <option value=\"2\" >2<\/option>\r\n                                                    <option value=\"3\" >3<\/option>\r\n                                                    <option value=\"4\" >4<\/option>\r\n                                                    <option value=\"5\" >5<\/option>\r\n                                                    <option value=\"6\" >6<\/option>\r\n                                                    <option value=\"7\" >7<\/option>\r\n                                                    <option value=\"8\" >8<\/option>\r\n                                                    <option value=\"9\" >9<\/option>\r\n                                                    <option value=\"10\" >10<\/option>\r\n                                                    <option value=\"11\" >11<\/option>\r\n                                                    <option value=\"12\" >12<\/option>\r\n                                                    <option value=\"13\" >13<\/option>\r\n                                                    <option value=\"14\" >14<\/option>\r\n                                                    <option value=\"15\" >15<\/option>\r\n                                                    <option value=\"16\" >16<\/option>\r\n                                                    <option value=\"17\" >17<\/option>\r\n                                                    <option value=\"18\" >18<\/option>\r\n                                                    <option value=\"19\" >19<\/option>\r\n                                                    <option value=\"20\" >20<\/option>\r\n                                                    <option value=\"21\" >21<\/option>\r\n                                                    <option value=\"22\" >22<\/option>\r\n                                                    <option value=\"23\" >23<\/option>\r\n                                                    <option value=\"24\" >24<\/option>\r\n                                                    <option value=\"25\" >25<\/option>\r\n                                                    <option value=\"26\" >26<\/option>\r\n                                                    <option value=\"27\" >27<\/option>\r\n                                                    <option value=\"28\" >28<\/option>\r\n                                                    <option value=\"29\" >29<\/option>\r\n                                                    <option value=\"30\" >30<\/option>\r\n                                                    <option value=\"31\" >31<\/option>\r\n                                            <\/select>\r\n                                        <label id=\"iphorm_4_4_6acc3aa335143_month_label\" class=\"iphorm-screen-reader-text\">Month<\/label>\r\n                    <select id=\"iphorm_4_4_6acc3aa335143_month\" name=\"iphorm_4_4[month]\" class=\"iphorm_4_4-input-month\" aria-labelledby=\"iphorm_4_4_6acc3aa335143_date_label iphorm_4_4_6acc3aa335143_month_label\" >\r\n                        <option value=\"\">Month<\/option>                                                    <option value=\"1\" >1<\/option>\r\n                                                    <option value=\"2\" >2<\/option>\r\n                                                    <option value=\"3\" >3<\/option>\r\n                                                    <option value=\"4\" >4<\/option>\r\n                                                    <option value=\"5\" >5<\/option>\r\n                                                    <option value=\"6\" >6<\/option>\r\n                                                    <option value=\"7\" >7<\/option>\r\n                                                    <option value=\"8\" >8<\/option>\r\n                                                    <option value=\"9\" >9<\/option>\r\n                                                    <option value=\"10\" >10<\/option>\r\n                                                    <option value=\"11\" >11<\/option>\r\n                                                    <option value=\"12\" >12<\/option>\r\n                                            <\/select>\r\n                                        <label id=\"iphorm_4_4_6acc3aa335143_year_label\" class=\"iphorm-screen-reader-text\">Year<\/label>\r\n                    <select id=\"iphorm_4_4_6acc3aa335143_year\" name=\"iphorm_4_4[year]\" class=\"iphorm_4_4-input-year\" aria-labelledby=\"iphorm_4_4_6acc3aa335143_date_label iphorm_4_4_6acc3aa335143_year_label\" >\r\n                        <option value=\"\">Year<\/option>                                                                                    <option value=\"2030\" >2030<\/option>\r\n                                                            <option value=\"2029\" >2029<\/option>\r\n                                                            <option value=\"2028\" >2028<\/option>\r\n                                                            <option value=\"2027\" >2027<\/option>\r\n                                                            <option value=\"2026\" >2026<\/option>\r\n                                                            <option value=\"2025\" >2025<\/option>\r\n                                                            <option value=\"2024\" >2024<\/option>\r\n                                                            <option value=\"2023\" >2023<\/option>\r\n                                                            <option value=\"2022\" >2022<\/option>\r\n                                                            <option value=\"2021\" >2021<\/option>\r\n                                                            <option value=\"2020\" >2020<\/option>\r\n                                                            <option value=\"2019\" >2019<\/option>\r\n                                                            <option value=\"2018\" >2018<\/option>\r\n                                                            <option value=\"2017\" >2017<\/option>\r\n                                                            <option value=\"2016\" >2016<\/option>\r\n                                                            <option value=\"2015\" >2015<\/option>\r\n                                                            <option value=\"2014\" >2014<\/option>\r\n                                                            <option value=\"2013\" >2013<\/option>\r\n                                                            <option value=\"2012\" >2012<\/option>\r\n                                                            <option value=\"2011\" >2011<\/option>\r\n                                                            <option value=\"2010\" >2010<\/option>\r\n                                                            <option value=\"2009\" >2009<\/option>\r\n                                                            <option value=\"2008\" >2008<\/option>\r\n                                                            <option value=\"2007\" >2007<\/option>\r\n                                                            <option value=\"2006\" >2006<\/option>\r\n                                                            <option value=\"2005\" >2005<\/option>\r\n                                                            <option value=\"2004\" >2004<\/option>\r\n                                                            <option value=\"2003\" >2003<\/option>\r\n                                                            <option value=\"2002\" >2002<\/option>\r\n                                                            <option value=\"2001\" >2001<\/option>\r\n                                                            <option value=\"2000\" >2000<\/option>\r\n                                                            <option value=\"1999\" >1999<\/option>\r\n                                                            <option value=\"1998\" >1998<\/option>\r\n                                                            <option value=\"1997\" >1997<\/option>\r\n                                                            <option value=\"1996\" >1996<\/option>\r\n                                                            <option value=\"1995\" >1995<\/option>\r\n                                                            <option value=\"1994\" >1994<\/option>\r\n                                                            <option value=\"1993\" >1993<\/option>\r\n                                                            <option value=\"1992\" >1992<\/option>\r\n                                                            <option value=\"1991\" >1991<\/option>\r\n                                                            <option value=\"1990\" >1990<\/option>\r\n                                                            <option value=\"1989\" >1989<\/option>\r\n                                                            <option value=\"1988\" >1988<\/option>\r\n                                                            <option value=\"1987\" >1987<\/option>\r\n                                                            <option value=\"1986\" >1986<\/option>\r\n                                                            <option value=\"1985\" >1985<\/option>\r\n                                                            <option value=\"1984\" >1984<\/option>\r\n                                                            <option value=\"1983\" >1983<\/option>\r\n                                                            <option value=\"1982\" >1982<\/option>\r\n                                                            <option value=\"1981\" >1981<\/option>\r\n                                                            <option value=\"1980\" >1980<\/option>\r\n                                                            <option value=\"1979\" >1979<\/option>\r\n                                                            <option value=\"1978\" >1978<\/option>\r\n                                                            <option value=\"1977\" >1977<\/option>\r\n                                                            <option value=\"1976\" >1976<\/option>\r\n                                                            <option value=\"1975\" >1975<\/option>\r\n                                                            <option value=\"1974\" >1974<\/option>\r\n                                                            <option value=\"1973\" >1973<\/option>\r\n                                                            <option value=\"1972\" >1972<\/option>\r\n                                                            <option value=\"1971\" >1971<\/option>\r\n                                                            <option value=\"1970\" >1970<\/option>\r\n                                                            <option value=\"1969\" >1969<\/option>\r\n                                                            <option value=\"1968\" >1968<\/option>\r\n                                                            <option value=\"1967\" >1967<\/option>\r\n                                                            <option value=\"1966\" >1966<\/option>\r\n                                                            <option value=\"1965\" >1965<\/option>\r\n                                                            <option value=\"1964\" >1964<\/option>\r\n                                                            <option value=\"1963\" >1963<\/option>\r\n                                                            <option value=\"1962\" >1962<\/option>\r\n                                                            <option value=\"1961\" >1961<\/option>\r\n                                                            <option value=\"1960\" >1960<\/option>\r\n                                                            <option value=\"1959\" >1959<\/option>\r\n                                                            <option value=\"1958\" >1958<\/option>\r\n                                                            <option value=\"1957\" >1957<\/option>\r\n                                                            <option value=\"1956\" >1956<\/option>\r\n                                                            <option value=\"1955\" >1955<\/option>\r\n                                                            <option value=\"1954\" >1954<\/option>\r\n                                                            <option value=\"1953\" >1953<\/option>\r\n                                                            <option value=\"1952\" >1952<\/option>\r\n                                                            <option value=\"1951\" >1951<\/option>\r\n                                                            <option value=\"1950\" >1950<\/option>\r\n                                                            <option value=\"1949\" >1949<\/option>\r\n                                                            <option value=\"1948\" >1948<\/option>\r\n                                                            <option value=\"1947\" >1947<\/option>\r\n                                                            <option value=\"1946\" >1946<\/option>\r\n                                                            <option value=\"1945\" >1945<\/option>\r\n                                                            <option value=\"1944\" >1944<\/option>\r\n                                                            <option value=\"1943\" >1943<\/option>\r\n                                                            <option value=\"1942\" >1942<\/option>\r\n                                                            <option value=\"1941\" >1941<\/option>\r\n                                                            <option value=\"1940\" >1940<\/option>\r\n                                                            <option value=\"1939\" >1939<\/option>\r\n                                                            <option value=\"1938\" >1938<\/option>\r\n                                                            <option value=\"1937\" >1937<\/option>\r\n                                                            <option value=\"1936\" >1936<\/option>\r\n                                                            <option value=\"1935\" >1935<\/option>\r\n                                                            <option value=\"1934\" >1934<\/option>\r\n                                                            <option value=\"1933\" >1933<\/option>\r\n                                                            <option value=\"1932\" >1932<\/option>\r\n                                                            <option value=\"1931\" >1931<\/option>\r\n                                                            <option value=\"1930\" >1930<\/option>\r\n                                                            <option value=\"1929\" >1929<\/option>\r\n                                                            <option value=\"1928\" >1928<\/option>\r\n                                                            <option value=\"1927\" >1927<\/option>\r\n                                                            <option value=\"1926\" >1926<\/option>\r\n                                                            <option value=\"1925\" >1925<\/option>\r\n                                                            <option value=\"1924\" >1924<\/option>\r\n                                                            <option value=\"1923\" >1923<\/option>\r\n                                                            <option value=\"1922\" >1922<\/option>\r\n                                                            <option value=\"1921\" >1921<\/option>\r\n                                                            <option value=\"1920\" >1920<\/option>\r\n                                                            <option value=\"1919\" >1919<\/option>\r\n                                                            <option value=\"1918\" >1918<\/option>\r\n                                                            <option value=\"1917\" >1917<\/option>\r\n                                                            <option value=\"1916\" >1916<\/option>\r\n                                                            <option value=\"1915\" >1915<\/option>\r\n                                                            <option value=\"1914\" >1914<\/option>\r\n                                                            <option value=\"1913\" >1913<\/option>\r\n                                                            <option value=\"1912\" >1912<\/option>\r\n                                                            <option value=\"1911\" >1911<\/option>\r\n                                                            <option value=\"1910\" >1910<\/option>\r\n                                                            <option value=\"1909\" >1909<\/option>\r\n                                                            <option value=\"1908\" >1908<\/option>\r\n                                                            <option value=\"1907\" >1907<\/option>\r\n                                                            <option value=\"1906\" >1906<\/option>\r\n                                                            <option value=\"1905\" >1905<\/option>\r\n                                                            <option value=\"1904\" >1904<\/option>\r\n                                                            <option value=\"1903\" >1903<\/option>\r\n                                                            <option value=\"1902\" >1902<\/option>\r\n                                                            <option value=\"1901\" >1901<\/option>\r\n                                                            <option value=\"1900\" >1900<\/option>\r\n                                                                        <\/select>\r\n                <\/div>\r\n                            <\/div>\r\n                    <\/div>\r\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\r\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-time iphorm_4_5-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-time iphorm_4_5-element-spacer\">\n        <label id=\"iphorm_4_5_6acc3aa335143_time_label\" class=\"iphorm_4_5-outer-label\" >Exact time of birth (hours and minutes):<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-date iphorm_4_5-input-wrap\" >\n            <label id=\"iphorm_4_5_6acc3aa335143_hour_label\" class=\"iphorm-screen-reader-text\">Hour<\/label>\n            <select id=\"iphorm_4_5_6acc3aa335143_hour\"  name=\"iphorm_4_5[hour]\" class=\"iphorm_4_5-input-hour\" aria-labelledby=\"iphorm_4_5_6acc3aa335143_time_label iphorm_4_5_6acc3aa335143_hour_label\" >\n                <option value=\"\">HH<\/option>                                                                                    <option value=\"00\" >00<\/option>\n                                                                    <option value=\"01\" >01<\/option>\n                                                                    <option value=\"02\" >02<\/option>\n                                                                    <option value=\"03\" >03<\/option>\n                                                                    <option value=\"04\" >04<\/option>\n                                                                    <option value=\"05\" >05<\/option>\n                                                                    <option value=\"06\" >06<\/option>\n                                                                    <option value=\"07\" >07<\/option>\n                                                                    <option value=\"08\" >08<\/option>\n                                                                    <option value=\"09\" >09<\/option>\n                                                                    <option value=\"10\" >10<\/option>\n                                                                    <option value=\"11\" >11<\/option>\n                                                                    <option value=\"12\"  selected='selected'>12<\/option>\n                                                                    <option value=\"13\" >13<\/option>\n                                                                    <option value=\"14\" >14<\/option>\n                                                                    <option value=\"15\" >15<\/option>\n                                                                    <option value=\"16\" >16<\/option>\n                                                                    <option value=\"17\" >17<\/option>\n                                                                    <option value=\"18\" >18<\/option>\n                                                                    <option value=\"19\" >19<\/option>\n                                                                    <option value=\"20\" >20<\/option>\n                                                                    <option value=\"21\" >21<\/option>\n                                                                    <option value=\"22\" >22<\/option>\n                                                                    <option value=\"23\" >23<\/option>\n                                                <\/select>\n            <label id=\"iphorm_4_5_6acc3aa335143_minute_label\" class=\"iphorm-screen-reader-text\">Minute<\/label>\n            <select id=\"iphorm_4_5_6acc3aa335143_minute\" name=\"iphorm_4_5[minute]\" class=\"iphorm_4_5-input-minute\" aria-labelledby=\"iphorm_4_5_6acc3aa335143_time_label iphorm_4_5_6acc3aa335143_minute_label\" >\n                <option value=\"\">MM<\/option>                                                                                    <option value=\"00\"  selected='selected'>00<\/option>\n                                                                                                        <option value=\"01\" >01<\/option>\n                                                                                                        <option value=\"02\" >02<\/option>\n                                                                                                        <option value=\"03\" >03<\/option>\n                                                                                                        <option value=\"04\" >04<\/option>\n                                                                                                        <option value=\"05\" >05<\/option>\n                                                                                                        <option value=\"06\" >06<\/option>\n                                                                                                        <option value=\"07\" >07<\/option>\n                                                                                                        <option value=\"08\" >08<\/option>\n                                                                                                        <option value=\"09\" >09<\/option>\n                                                                                                        <option value=\"10\" >10<\/option>\n                                                                                                        <option value=\"11\" >11<\/option>\n                                                                                                        <option value=\"12\" >12<\/option>\n                                                                                                        <option value=\"13\" >13<\/option>\n                                                                                                        <option value=\"14\" >14<\/option>\n                                                                                                        <option value=\"15\" >15<\/option>\n                                                                                                        <option value=\"16\" >16<\/option>\n                                                                                                        <option value=\"17\" >17<\/option>\n                                                                                                        <option value=\"18\" >18<\/option>\n                                                                                                        <option value=\"19\" >19<\/option>\n                                                                                                        <option value=\"20\" >20<\/option>\n                                                                                                        <option value=\"21\" >21<\/option>\n                                                                                                        <option value=\"22\" >22<\/option>\n                                                                                                        <option value=\"23\" >23<\/option>\n                                                                                                        <option value=\"24\" >24<\/option>\n                                                                                                        <option value=\"25\" >25<\/option>\n                                                                                                        <option value=\"26\" >26<\/option>\n                                                                                                        <option value=\"27\" >27<\/option>\n                                                                                                        <option value=\"28\" >28<\/option>\n                                                                                                        <option value=\"29\" >29<\/option>\n                                                                                                        <option value=\"30\" >30<\/option>\n                                                                                                        <option value=\"31\" >31<\/option>\n                                                                                                        <option value=\"32\" >32<\/option>\n                                                                                                        <option value=\"33\" >33<\/option>\n                                                                                                        <option value=\"34\" >34<\/option>\n                                                                                                        <option value=\"35\" >35<\/option>\n                                                                                                        <option value=\"36\" >36<\/option>\n                                                                                                        <option value=\"37\" >37<\/option>\n                                                                                                        <option value=\"38\" >38<\/option>\n                                                                                                        <option value=\"39\" >39<\/option>\n                                                                                                        <option value=\"40\" >40<\/option>\n                                                                                                        <option value=\"41\" >41<\/option>\n                                                                                                        <option value=\"42\" >42<\/option>\n                                                                                                        <option value=\"43\" >43<\/option>\n                                                                                                        <option value=\"44\" >44<\/option>\n                                                                                                        <option value=\"45\" >45<\/option>\n                                                                                                        <option value=\"46\" >46<\/option>\n                                                                                                        <option value=\"47\" >47<\/option>\n                                                                                                        <option value=\"48\" >48<\/option>\n                                                                                                        <option value=\"49\" >49<\/option>\n                                                                                                        <option value=\"50\" >50<\/option>\n                                                                                                        <option value=\"51\" >51<\/option>\n                                                                                                        <option value=\"52\" >52<\/option>\n                                                                                                        <option value=\"53\" >53<\/option>\n                                                                                                        <option value=\"54\" >54<\/option>\n                                                                                                        <option value=\"55\" >55<\/option>\n                                                                                                        <option value=\"56\" >56<\/option>\n                                                                                                        <option value=\"57\" >57<\/option>\n                                                                                                        <option value=\"58\" >58<\/option>\n                                                                                                        <option value=\"59\" >59<\/option>\n                                                <\/select>\n                            <input type=\"hidden\" name=\"iphorm_4_5[ampm]\" value=\"\" \/>\n                                <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_4_6-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_4_6-element-spacer\">\n        <label class=\"iphorm_4_6-outer-label\" >If you don\u2019t know the exact time of birth, enter the approximate time and tick this box:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_4_6-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_4_6-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_6-input-li\" >\n                    <label for=\"iphorm_4_6_6acc3aa335143_1\"  class=\"iphorm_4_6_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_6 iphorm_4_6_1\" type=\"checkbox\" name=\"iphorm_4_6[]\" id=\"iphorm_4_6_6acc3aa335143_1\" value=\"I know the approximate time of birth only.\"  \/>\n                        I know the approximate time of birth only.                    <\/label>\n                <\/div>\n                        <\/div>\n                <p class=\"iphorm-description\" >Attention! If you don\u2019t know the exact time of birth, predictions may be inaccurate. The approximate time of birth can be stated for psychological and compatibility horoscopes. The more exact time of birth is stated, the more accurate the prediction is!<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_4_9-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_4_9-element-spacer\">\n        <label for=\"iphorm_4_9_6acc3aa335143\" class=\"iphorm_4_9-outer-label\" >Exact country of birth:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_4_9-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_4_9\" id=\"iphorm_4_9_6acc3aa335143\" type=\"text\" name=\"iphorm_4_9\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_4_10-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_4_10-element-spacer\">\n        <label for=\"iphorm_4_10_6acc3aa335143\" class=\"iphorm_4_10-outer-label\" >Exact city of birth:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_4_10-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_4_10\" id=\"iphorm_4_10_6acc3aa335143\" type=\"text\" name=\"iphorm_4_10\"  value=\"\"  \/>\n                <p class=\"iphorm-description\" >(If your child was born in a small settlement, state the closest city.)<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_4_11-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_4_11-element-spacer\">\n        <label for=\"iphorm_4_11_6acc3aa335143\" class=\"iphorm_4_11-outer-label\" >Country where your child lives in now:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_4_11-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_4_11\" id=\"iphorm_4_11_6acc3aa335143\" type=\"text\" name=\"iphorm_4_11\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_4_12-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_4_12-element-spacer\">\n        <label for=\"iphorm_4_12_6acc3aa335143\" class=\"iphorm_4_12-outer-label\" >City where your child lives in now:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_4_12-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_4_12\" id=\"iphorm_4_12_6acc3aa335143\" type=\"text\" name=\"iphorm_4_12\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_4_35-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_4_35-element-spacer\">\n        <label class=\"iphorm_4_35-outer-label\" >Did you experience any traumas while giving birth?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_4_35-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_4_35-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_35-input-li\" >\n                    <label for=\"iphorm_4_35_6acc3aa335143_1\"  class=\"iphorm_4_35_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_35 iphorm_4_35_1\" type=\"checkbox\" name=\"iphorm_4_35[]\" id=\"iphorm_4_35_6acc3aa335143_1\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_35-input-li\" >\n                    <label for=\"iphorm_4_35_6acc3aa335143_2\"  class=\"iphorm_4_35_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_35 iphorm_4_35_2\" type=\"checkbox\" name=\"iphorm_4_35[]\" id=\"iphorm_4_35_6acc3aa335143_2\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_4_36-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_4_36-element-spacer\">\n        <label for=\"iphorm_4_36_6acc3aa335143\" class=\"iphorm_4_36-outer-label\" >What kind?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_4_36-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_4_36\" id=\"iphorm_4_36_6acc3aa335143\" type=\"text\" name=\"iphorm_4_36\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_4_41-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_4_41-element-spacer\">\n        <label class=\"iphorm_4_41-outer-label\" >Was your child born full-term?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_4_41-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_4_41-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_41-input-li\" >\n                    <label for=\"iphorm_4_41_6acc3aa335143_1\"  class=\"iphorm_4_41_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_41 iphorm_4_41_1\" type=\"checkbox\" name=\"iphorm_4_41[]\" id=\"iphorm_4_41_6acc3aa335143_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_41-input-li\" >\n                    <label for=\"iphorm_4_41_6acc3aa335143_2\"  class=\"iphorm_4_41_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_41 iphorm_4_41_2\" type=\"checkbox\" name=\"iphorm_4_41[]\" id=\"iphorm_4_41_6acc3aa335143_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_4_42-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_4_42-element-spacer\">\n        <label for=\"iphorm_4_42_6acc3aa335143\" class=\"iphorm_4_42-outer-label\" >How many months?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_4_42-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_4_42\" id=\"iphorm_4_42_6acc3aa335143\" type=\"text\" name=\"iphorm_4_42\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_4_37-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_4_37-element-spacer\">\n        <label for=\"iphorm_4_37_6acc3aa335143\" class=\"iphorm_4_37-outer-label\" >How many children do you have at all?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_4_37-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_4_37\" id=\"iphorm_4_37_6acc3aa335143\" type=\"text\" name=\"iphorm_4_37\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_4_38-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_4_38-element-spacer\">\n        <label class=\"iphorm_4_38-outer-label\" >This child of yours is:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_4_38-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_4_38-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_38-input-li\" >\n                    <label for=\"iphorm_4_38_6acc3aa335143_1\"  class=\"iphorm_4_38_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_38 iphorm_4_38_1\" type=\"checkbox\" name=\"iphorm_4_38[]\" id=\"iphorm_4_38_6acc3aa335143_1\" value=\"First\"  \/>\n                        First                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_38-input-li\" >\n                    <label for=\"iphorm_4_38_6acc3aa335143_2\"  class=\"iphorm_4_38_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_38 iphorm_4_38_2\" type=\"checkbox\" name=\"iphorm_4_38[]\" id=\"iphorm_4_38_6acc3aa335143_2\" value=\"Second\"  \/>\n                        Second                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_38-input-li\" >\n                    <label for=\"iphorm_4_38_6acc3aa335143_3\"  class=\"iphorm_4_38_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_38 iphorm_4_38_3\" type=\"checkbox\" name=\"iphorm_4_38[]\" id=\"iphorm_4_38_6acc3aa335143_3\" value=\"Third\"  \/>\n                        Third                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_38-input-li\" >\n                    <label for=\"iphorm_4_38_6acc3aa335143_4\"  class=\"iphorm_4_38_4_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_38 iphorm_4_38_4\" type=\"checkbox\" name=\"iphorm_4_38[]\" id=\"iphorm_4_38_6acc3aa335143_4\" value=\"Other\"  \/>\n                        Other                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_4_39-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_4_39-element-spacer\">\n        <label for=\"iphorm_4_39_6acc3aa335143\" class=\"iphorm_4_39-outer-label\" >\u012era\u0161ykite kelintas yra \u0161is J\u016bs\u0173 vaikas:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_4_39-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_4_39\" id=\"iphorm_4_39_6acc3aa335143\" type=\"text\" name=\"iphorm_4_39\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-textarea iphorm_4_21-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-textarea iphorm_4_21-element-spacer\">\n        <label for=\"iphorm_4_21_6acc3aa335143\" class=\"iphorm_4_21-outer-label\" >You can write down the specific issues you are interested in or what specifically the astrologer should take into account when analyzing the Horoscope:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-textarea iphorm_4_21-input-wrap\" >\n            <textarea class=\"iphorm-element-textarea  iphorm_4_21\" id=\"iphorm_4_21_6acc3aa335143\" name=\"iphorm_4_21\"   rows=\"5\" cols=\"25\"><\/textarea>\n                <p class=\"iphorm-description\" >The clearer and more specific you formulate the questions and issues you are interested in, the more accurately we will be able to present information to you on the basis of your horoscope.<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_4_22-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_4_22-element-spacer\">\n        <label class=\"iphorm_4_22-outer-label\" >May we contact you should the astrologer have any questions regarding more specific data?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_4_22-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_4_22-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_22-input-li\" >\n                    <label for=\"iphorm_4_22_6acc3aa335143_1\"  class=\"iphorm_4_22_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_22 iphorm_4_22_1\" type=\"checkbox\" name=\"iphorm_4_22[]\" id=\"iphorm_4_22_6acc3aa335143_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_22-input-li\" >\n                    <label for=\"iphorm_4_22_6acc3aa335143_2\"  class=\"iphorm_4_22_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_22 iphorm_4_22_2\" type=\"checkbox\" name=\"iphorm_4_22[]\" id=\"iphorm_4_22_6acc3aa335143_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_4_23-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_4_23-element-spacer\">\n        <label for=\"iphorm_4_23_6acc3aa335143\" class=\"iphorm_4_23-outer-label\" >Telephone number:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_4_23-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_4_23\" id=\"iphorm_4_23_6acc3aa335143\" type=\"text\" name=\"iphorm_4_23\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_4_24-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_4_24-element-spacer\">\n        <label for=\"iphorm_4_24_6acc3aa335143\" class=\"iphorm_4_24-outer-label\" >E-mail:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_4_24-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_4_24\" id=\"iphorm_4_24_6acc3aa335143\" type=\"text\" name=\"iphorm_4_24\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_4_25-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_4_25-element-spacer\">\n        <label class=\"iphorm_4_25-outer-label\" >Please state in which way you wish to receive the Horoscope you have ordered in a written form:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_4_25-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_4_25-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_25-input-li\" >\n                    <label for=\"iphorm_4_25_6acc3aa335143_1\"  class=\"iphorm_4_25_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_25 iphorm_4_25_1\" type=\"checkbox\" name=\"iphorm_4_25[]\" id=\"iphorm_4_25_6acc3aa335143_1\" value=\"By e-mail\"  \/>\n                        By e-mail                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_25-input-li\" >\n                    <label for=\"iphorm_4_25_6acc3aa335143_2\"  class=\"iphorm_4_25_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_25 iphorm_4_25_2\" type=\"checkbox\" name=\"iphorm_4_25[]\" id=\"iphorm_4_25_6acc3aa335143_2\" value=\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"  \/>\n                        By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_4_26-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_4_26-element-spacer\">\n        <label for=\"iphorm_4_26_6acc3aa335143\" class=\"iphorm_4_26-outer-label\" >State e-mail address at which you wish to receive the horoscope in a written form:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_4_26-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_4_26\" id=\"iphorm_4_26_6acc3aa335143\" type=\"text\" name=\"iphorm_4_26\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-html iphorm_4_28-element-wrap iphorm-clearfix\">\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-html iphorm_4_28-element-spacer\">\n        Please state your exact address at which we could send the Horoscope:    <\/div>\n<\/div>\n<div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_4_27-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_4_27-element-spacer\">\n        <label for=\"iphorm_4_27_6acc3aa335143\" class=\"iphorm_4_27-outer-label\" >Country:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_4_27-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_4_27\" id=\"iphorm_4_27_6acc3aa335143\" type=\"text\" name=\"iphorm_4_27\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_4_29-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_4_29-element-spacer\">\n        <label for=\"iphorm_4_29_6acc3aa335143\" class=\"iphorm_4_29-outer-label\" >City:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_4_29-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_4_29\" id=\"iphorm_4_29_6acc3aa335143\" type=\"text\" name=\"iphorm_4_29\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_4_30-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_4_30-element-spacer\">\n        <label for=\"iphorm_4_30_6acc3aa335143\" class=\"iphorm_4_30-outer-label\" >Street:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_4_30-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_4_30\" id=\"iphorm_4_30_6acc3aa335143\" type=\"text\" name=\"iphorm_4_30\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_4_31-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_4_31-element-spacer\">\n        <label for=\"iphorm_4_31_6acc3aa335143\" class=\"iphorm_4_31-outer-label\" >House:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_4_31-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_4_31\" id=\"iphorm_4_31_6acc3aa335143\" type=\"text\" name=\"iphorm_4_31\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_4_32-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_4_32-element-spacer\">\n        <label for=\"iphorm_4_32_6acc3aa335143\" class=\"iphorm_4_32-outer-label\" >Apartment:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_4_32-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_4_32\" id=\"iphorm_4_32_6acc3aa335143\" type=\"text\" name=\"iphorm_4_32\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_4_33-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_4_33-element-spacer\">\n        <label class=\"iphorm_4_33-outer-label\" >Order confirmation:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_4_33-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_4_33-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_4_33-input-li\" >\n                    <label for=\"iphorm_4_33_6acc3aa335143_1\"  class=\"iphorm_4_33_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_4_33 iphorm_4_33_1\" type=\"checkbox\" name=\"iphorm_4_33[]\" id=\"iphorm_4_33_6acc3aa335143_1\" value=\"I order a horoscope and guarantee that the data presented in the registration form is true.\"  \/>\n                        I order a horoscope and guarantee that the data presented in the registration form is true.                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-recaptcha g-recaptcha-response-element-wrap iphorm_4_44-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-required\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-captcha g-recaptcha-response-element-spacer\">\n        <label class=\"g-recaptcha-response-outer-label\" >Type the words<span class=\"iphorm-required\">(required)<\/span><\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-recaptcha g-recaptcha-response-input-wrap\" >\n                            <div id=\"iphorm_4_44_6acc3aa335143\" class=\"iphorm-recaptcha\" data-unique-id=\"iphorm_4_44_6acc3aa335143\" data-config=\"{&quot;sitekey&quot;:&quot;6LedJT8UAAAAAF98QMjpclkDUi0x8zoTC2M7u2VB&quot;,&quot;theme&quot;:&quot;light&quot;,&quot;type&quot;:&quot;image&quot;,&quot;size&quot;:&quot;normal&quot;}\"><\/div>\n                <noscript>\n                  <div style=\"width: 302px; height: 352px;\">\n                    <div style=\"width: 302px; height: 352px; position: relative;\">\n                      <div style=\"width: 302px; height: 352px; position: absolute;\">\n                        <iframe src=\"https:\/\/www.google.com\/recaptcha\/api\/fallback?k=6LedJT8UAAAAAF98QMjpclkDUi0x8zoTC2M7u2VB\"\n                                frameborder=\"0\" scrolling=\"no\"\n                                style=\"width: 302px; height:352px; border-style: none;\">\n                        <\/iframe>\n                      <\/div>\n                      <div style=\"width: 250px; height: 80px; position: absolute; border-style: none;\n                                  bottom: 21px; left: 25px; margin: 0px; padding: 0px; right: 25px;\">\n                        <textarea name=\"g-recaptcha-response\" class=\"g-recaptcha-response\"\n                                  style=\"width: 250px; height: 80px; border: 1px solid #c1c1c1;\n                                         margin: 0px; padding: 0px; resize: none;\"><\/textarea>\n                      <\/div>\n                    <\/div>\n                  <\/div>\n                <\/noscript>\n                                <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-hidden\">\n    <label>This field should be left blank<input type=\"text\" name=\"iphorm_4_0\" \/><\/label>\n<\/div>                <div class=\"iphorm-submit-wrap iphorm-submit-wrap-4 iphorm-clearfix\" >\n                    <div class=\"iphorm-submit-input-wrap iphorm-submit-input-wrap-4\" >\n                        <button class=\"iphorm-submit-element\" type=\"submit\" name=\"iphorm_submit\" ><span ><em >ORDER<\/em><\/span><\/button>\n                    <\/div>\n                    <div class=\"iphorm-loading-wrap\"><span class=\"iphorm-loading\">Please wait...<\/span><\/div>\n                <\/div>\n            <\/div>\n                                                                        <div class=\"iphorm-success-message iphorm-hidden\" ><\/div>\n                                    <\/div>\n            <\/form>\n    <script type=\"text\/javascript\">\n    jQuery('#iphorm-outer-6acc3aa335143 script').remove();\n    <\/script>\n<\/div>\t<\/div>\r\n\r\n\t<div class=\"hidden-form form-MH\">\r\n\t<div id=\"iphorm-outer-6acc3aa337628\" class=\"iphorm-outer iphorm-outer-5 iphorm-uniform-theme-default iphorm-theme-light-light iphorm-has-logic\" >\n    <script type=\"text\/javascript\">\n        jQuery(document).ready(function($) {\n                            iPhorm.logic[5] = {\"logic\":{\"14\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"13\",\"operator\":\"eq\",\"value\":\"Secondary-special\"},{\"element_id\":\"13\",\"operator\":\"eq\",\"value\":\"Higher\"}]},\"16\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"15\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"20\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"19\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"36\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"35\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"37\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"35\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"45\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"44\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"47\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"46\",\"operator\":\"eq\",\"value\":\"Often\"},{\"element_id\":\"46\",\"operator\":\"eq\",\"value\":\"Seldom\"}]},\"81\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"80\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"52\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"51\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"54\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"53\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"56\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"55\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"58\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"57\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"60\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"59\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"62\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"61\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"64\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"63\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"66\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"65\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"68\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"67\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"70\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"69\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"72\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"71\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"74\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"73\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"76\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"75\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"78\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"77\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"23\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"22\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"24\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"22\",\"operator\":\"eq\",\"value\":\"Yes\"}]},\"26\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By e-mail\"}]},\"28\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"27\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"29\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"30\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"31\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]},\"32\":{\"action\":\"show\",\"match\":\"any\",\"rules\":[{\"element_id\":\"25\",\"operator\":\"eq\",\"value\":\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"}]}},\"dependents\":{\"13\":[14,14],\"15\":[16],\"19\":[20],\"35\":[36,37],\"44\":[45],\"46\":[47,47],\"80\":[81],\"51\":[52],\"53\":[54],\"55\":[56],\"57\":[58],\"59\":[60],\"61\":[62],\"63\":[64],\"65\":[66],\"67\":[68],\"69\":[70],\"71\":[72],\"73\":[74],\"75\":[76],\"77\":[78],\"22\":[23,24],\"25\":[26,28,27,29,30,31,32]},\"animate\":true};\n                        $('#iphorm-6acc3aa337628').iPhorm({\"id\":5,\"uniqueId\":\"6acc3aa337628\",\"useAjax\":true,\"successMessageTimeout\":160,\"resetFormValues\":\"\",\"clElementIds\":[14,16,20,36,37,45,47,81,52,54,56,58,60,62,64,66,68,70,72,74,76,78,23,24,26,28,27,29,30,31,32],\"clDependentElementIds\":[13,15,19,35,44,46,80,51,53,55,57,59,61,63,65,67,69,71,73,75,77,22,25],\"centerFancybox\":true,\"centerFancyboxSpeed\":true});\n                        if ($.isFunction($.fn.qtip)) {\n                $('.iphorm-tooltip-hover', iPhorm.instance.$form).qtip({\n                    style: {\n                        classes: 'qtip-plain qtip-shadow'\n                    },\n                    position: {\n                        my: 'left center',\n                        at: 'right center',\n                        viewport: $(window),\n                        adjust: {\n                            method: 'shift'\n                        }\n                    }\n                });\n                $('.iphorm-tooltip-click', iPhorm.instance.$form).qtip({\n                    style: {\n                        classes: 'qtip-plain qtip-shadow'\n                    },\n                    position: {\n                        my: 'left center',\n                        at: 'right center',\n                        viewport: $(window),\n                        adjust: {\n                            method: 'shift'\n                        }\n                    },\n                    show: {\n                        event: 'focus'\n                    },\n                    hide: {\n                        event: 'unfocus'\n                    }\n                });\n                $('.iphorm-tooltip-icon-hover', iPhorm.instance.$form).qtip({\n                    style: {\n                        classes: 'qtip-plain qtip-shadow'\n                    },\n                    position: {\n                        my: 'left center',\n                        at: 'right center',\n                        viewport: $(window),\n                        adjust: {\n                            method: 'shift'\n                        }\n                    },\n                    content: {\n                        text: function (api) {\n                            return $(this).find('.iphorm-tooltip-icon-content').html();\n                        }\n                    }\n                });\n                $('.iphorm-tooltip-icon-click', iPhorm.instance.$form).qtip({\n                    style: {\n                        classes: 'qtip-plain qtip-shadow'\n                    },\n                    position: {\n                        my: 'left center',\n                        at: 'right center',\n                        viewport: $(window),\n                        adjust: {\n                            method: 'shift'\n                        }\n                    },\n                    show: {\n                        event: 'click'\n                    },\n                    hide: {\n                        event: 'unfocus'\n                    },\n                    content: {\n                        text: function (api) {\n                            return $(this).find('.iphorm-tooltip-icon-content').html();\n                        }\n                    }\n                });\n                $('.iphorm-labels-inside > .iphorm-element-spacer > label').hover(function () {\n                    $(this).siblings('.iphorm-input-wrap').find('.iphorm-tooltip-hover').qtip('show');\n                }, function () {\n                    $(this).siblings('.iphorm-input-wrap').find('.iphorm-tooltip-hover').qtip('hide');\n                });\n            }\n                                    if ($.isFunction($.fn.uniform)) {\n                $('select, input:checkbox, input:radio', iPhorm.instance.$form).uniform({context: iPhorm.instance.$form, selectAutoWidth: false});\n            }\n                        if ($.isFunction($.fn.inFieldLabels)) {\n                $('.iphorm-labels-inside:not(.iphorm-element-wrap-recaptcha) > .iphorm-element-spacer > label', iPhorm.instance.$form).inFieldLabels();\n            }\n                        $('.iphorm-group-row > div:last-child:not(:first-child)', iPhorm.instance.$form).add('.iphorm-group-row:last-child', iPhorm.instance.$form).addClass('last-child');\n                            iPhorm.instance.applyAllLogic(true);\n                $('#iphorm-outer-6acc3aa337628').css('visibility', 'visible');\n                    });\n    <\/script>\n    <form id=\"iphorm-6acc3aa337628\" class=\"iphorm iphorm-form-5\" action=\"\/en\/wp-json\/wp\/v2\/pages\/40#iphorm-6acc3aa337628\" method=\"post\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\">\n        <div class=\"iphorm-inner iphorm-inner-5\" >\n            <input type=\"hidden\" name=\"iphorm_id\" value=\"5\" \/>\n            <input type=\"hidden\" name=\"iphorm_uid\" value=\"6acc3aa337628\" \/>\n            <input type=\"hidden\" name=\"form_url\" value=\"http:\/\/www.e-astrology.eu\/en\/wp-json\/wp\/v2\/pages\/40\" \/>\n            <input type=\"hidden\" name=\"referring_url\" value=\"\" \/>\n            <input type=\"hidden\" name=\"post_id\" value=\"\" \/>\n            <input type=\"hidden\" name=\"post_title\" value=\"\" \/>\n                            <h3 class=\"iphorm-title\" >MEDICAL HOROSCOPE \u2013 ORDER FORM<\/h3>\n                                                <div class=\"iphorm-elements iphorm-elements-5 iphorm-clearfix\" >\n                Attention! Please complete all boxes of the questionnaire very carefully. The Centre guarantees that all information stated in the registration form and information concerning your horoscope is confidential and it shall not be disclosed to any third parties in any case. \n<br><\/br><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_86-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_86-element-spacer\">\n        <label class=\"iphorm_5_86-outer-label\" >Type (kind) of ORAL consultation:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_86-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_86-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_86-input-li\" >\n                    <label for=\"iphorm_5_86_6acc3aa337628_1\"  class=\"iphorm_5_86_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_86 iphorm_5_86_1\" type=\"checkbox\" name=\"iphorm_5_86[]\" id=\"iphorm_5_86_6acc3aa337628_1\" value=\"Consultation on SKYPE (cost 50 eur)\"  \/>\n                        Consultation on SKYPE (cost 50 eur)                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_86-input-li\" >\n                    <label for=\"iphorm_5_86_6acc3aa337628_2\"  class=\"iphorm_5_86_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_86 iphorm_5_86_2\" type=\"checkbox\" name=\"iphorm_5_86[]\" id=\"iphorm_5_86_6acc3aa337628_2\" value=\"Personal visit\/meeting (only in Vilnius, Lithuania)\"  \/>\n                        Personal visit\/meeting (only in Vilnius, Lithuania)                    <\/label>\n                <\/div>\n                        <\/div>\n                <p class=\"iphorm-description\" >Attention! The cost of personal consultation (meeting with the astrologer) is determined individually.<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_87-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_87-element-spacer\">\n        <label class=\"iphorm_5_87-outer-label\" >Order of the Horoscope in a written form:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_87-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_87-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_87-input-li\" >\n                    <label for=\"iphorm_5_87_6acc3aa337628_1\"  class=\"iphorm_5_87_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_87 iphorm_5_87_1\" type=\"checkbox\" name=\"iphorm_5_87[]\" id=\"iphorm_5_87_6acc3aa337628_1\" value=\"I want to order the Horoscope in a WRITTEN form\"  \/>\n                        I want to order the Horoscope in a WRITTEN form                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_79-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_79-element-spacer\">\n        <label class=\"iphorm_5_79-outer-label\" >I want to order the horoscope:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_79-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_79-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_79-input-li\" >\n                    <label for=\"iphorm_5_79_6acc3aa337628_1\"  class=\"iphorm_5_79_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_79 iphorm_5_79_1\" type=\"checkbox\" name=\"iphorm_5_79[]\" id=\"iphorm_5_79_6acc3aa337628_1\" value=\"in English Language \u2013 120 eur\"  \/>\n                        in English Language \u2013 120 eur                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_79-input-li\" >\n                    <label for=\"iphorm_5_79_6acc3aa337628_2\"  class=\"iphorm_5_79_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_79 iphorm_5_79_2\" type=\"checkbox\" name=\"iphorm_5_79[]\" id=\"iphorm_5_79_6acc3aa337628_2\" value=\"in Russian Language \u2013 60 eur\"  \/>\n                        in Russian Language \u2013 60 eur                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_79-input-li\" >\n                    <label for=\"iphorm_5_79_6acc3aa337628_3\"  class=\"iphorm_5_79_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_79 iphorm_5_79_3\" type=\"checkbox\" name=\"iphorm_5_79[]\" id=\"iphorm_5_79_6acc3aa337628_3\" value=\"in Lithuanian Language \u2013 120 eur\"  \/>\n                        in Lithuanian Language \u2013 120 eur                    <\/label>\n                <\/div>\n                        <\/div>\n                <p class=\"iphorm-description\" >The cost of a written horoscope depends on the chosen language<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_2-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_2-element-spacer\">\n        <label for=\"iphorm_5_2_6acc3aa337628\" class=\"iphorm_5_2-outer-label\" >Name and surname:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_2-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_2\" id=\"iphorm_5_2_6acc3aa337628\" type=\"text\" name=\"iphorm_5_2\"  value=\"\"  \/>\n                <p class=\"iphorm-description\" >* We need your name and surname to check and receive the bank transfer (payment of your order).<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_3-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_3-element-spacer\">\n        <label class=\"iphorm_5_3-outer-label\" >Sex:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_3-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_3-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_3-input-li\" >\n                    <label for=\"iphorm_5_3_6acc3aa337628_1\"  class=\"iphorm_5_3_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_3 iphorm_5_3_1\" type=\"checkbox\" name=\"iphorm_5_3[]\" id=\"iphorm_5_3_6acc3aa337628_1\" value=\"Male\"  \/>\n                        Male                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_3-input-li\" >\n                    <label for=\"iphorm_5_3_6acc3aa337628_2\"  class=\"iphorm_5_3_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_3 iphorm_5_3_2\" type=\"checkbox\" name=\"iphorm_5_3[]\" id=\"iphorm_5_3_6acc3aa337628_2\" value=\"Female\"  \/>\n                        Female                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-date iphorm_5_4-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\r\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-date iphorm_5_4-element-spacer\">\r\n        <label id=\"iphorm_5_4_6acc3aa337628_date_label\" class=\"iphorm_5_4-outer-label\" >Date of birth:<\/label>        <div id=\"iphorm_5_4_6acc3aa337628\" class=\"iphorm-input-wrap iphorm-input-wrap-date iphorm_5_4-input-wrap\" >\r\n        \t<div class=\"iphorm-clearfix\">\r\n                <div class=\"iphorm-input-wrap-date-select-wrap\">\r\n                                                                                <label id=\"iphorm_5_4_6acc3aa337628_day_label\" class=\"iphorm-screen-reader-text\">Day<\/label>\r\n                    <select id=\"iphorm_5_4_6acc3aa337628_day\" name=\"iphorm_5_4[day]\" class=\"iphorm_5_4-input-day\" aria-labelledby=\"iphorm_5_4_6acc3aa337628_date_label iphorm_5_4_6acc3aa337628_day_label\" >\r\n                        <option value=\"\">Day<\/option>                                                    <option value=\"1\" >1<\/option>\r\n                                                    <option value=\"2\" >2<\/option>\r\n                                                    <option value=\"3\" >3<\/option>\r\n                                                    <option value=\"4\" >4<\/option>\r\n                                                    <option value=\"5\" >5<\/option>\r\n                                                    <option value=\"6\" >6<\/option>\r\n                                                    <option value=\"7\" >7<\/option>\r\n                                                    <option value=\"8\" >8<\/option>\r\n                                                    <option value=\"9\" >9<\/option>\r\n                                                    <option value=\"10\" >10<\/option>\r\n                                                    <option value=\"11\" >11<\/option>\r\n                                                    <option value=\"12\" >12<\/option>\r\n                                                    <option value=\"13\" >13<\/option>\r\n                                                    <option value=\"14\" >14<\/option>\r\n                                                    <option value=\"15\" >15<\/option>\r\n                                                    <option value=\"16\" >16<\/option>\r\n                                                    <option value=\"17\" >17<\/option>\r\n                                                    <option value=\"18\" >18<\/option>\r\n                                                    <option value=\"19\" >19<\/option>\r\n                                                    <option value=\"20\" >20<\/option>\r\n                                                    <option value=\"21\" >21<\/option>\r\n                                                    <option value=\"22\" >22<\/option>\r\n                                                    <option value=\"23\" >23<\/option>\r\n                                                    <option value=\"24\" >24<\/option>\r\n                                                    <option value=\"25\" >25<\/option>\r\n                                                    <option value=\"26\" >26<\/option>\r\n                                                    <option value=\"27\" >27<\/option>\r\n                                                    <option value=\"28\" >28<\/option>\r\n                                                    <option value=\"29\" >29<\/option>\r\n                                                    <option value=\"30\" >30<\/option>\r\n                                                    <option value=\"31\" >31<\/option>\r\n                                            <\/select>\r\n                                        <label id=\"iphorm_5_4_6acc3aa337628_month_label\" class=\"iphorm-screen-reader-text\">Month<\/label>\r\n                    <select id=\"iphorm_5_4_6acc3aa337628_month\" name=\"iphorm_5_4[month]\" class=\"iphorm_5_4-input-month\" aria-labelledby=\"iphorm_5_4_6acc3aa337628_date_label iphorm_5_4_6acc3aa337628_month_label\" >\r\n                        <option value=\"\">Month<\/option>                                                    <option value=\"1\" >1<\/option>\r\n                                                    <option value=\"2\" >2<\/option>\r\n                                                    <option value=\"3\" >3<\/option>\r\n                                                    <option value=\"4\" >4<\/option>\r\n                                                    <option value=\"5\" >5<\/option>\r\n                                                    <option value=\"6\" >6<\/option>\r\n                                                    <option value=\"7\" >7<\/option>\r\n                                                    <option value=\"8\" >8<\/option>\r\n                                                    <option value=\"9\" >9<\/option>\r\n                                                    <option value=\"10\" >10<\/option>\r\n                                                    <option value=\"11\" >11<\/option>\r\n                                                    <option value=\"12\" >12<\/option>\r\n                                            <\/select>\r\n                                        <label id=\"iphorm_5_4_6acc3aa337628_year_label\" class=\"iphorm-screen-reader-text\">Year<\/label>\r\n                    <select id=\"iphorm_5_4_6acc3aa337628_year\" name=\"iphorm_5_4[year]\" class=\"iphorm_5_4-input-year\" aria-labelledby=\"iphorm_5_4_6acc3aa337628_date_label iphorm_5_4_6acc3aa337628_year_label\" >\r\n                        <option value=\"\">Year<\/option>                                                                                    <option value=\"2030\" >2030<\/option>\r\n                                                            <option value=\"2029\" >2029<\/option>\r\n                                                            <option value=\"2028\" >2028<\/option>\r\n                                                            <option value=\"2027\" >2027<\/option>\r\n                                                            <option value=\"2026\" >2026<\/option>\r\n                                                            <option value=\"2025\" >2025<\/option>\r\n                                                            <option value=\"2024\" >2024<\/option>\r\n                                                            <option value=\"2023\" >2023<\/option>\r\n                                                            <option value=\"2022\" >2022<\/option>\r\n                                                            <option value=\"2021\" >2021<\/option>\r\n                                                            <option value=\"2020\" >2020<\/option>\r\n                                                            <option value=\"2019\" >2019<\/option>\r\n                                                            <option value=\"2018\" >2018<\/option>\r\n                                                            <option value=\"2017\" >2017<\/option>\r\n                                                            <option value=\"2016\" >2016<\/option>\r\n                                                            <option value=\"2015\" >2015<\/option>\r\n                                                            <option value=\"2014\" >2014<\/option>\r\n                                                            <option value=\"2013\" >2013<\/option>\r\n                                                            <option value=\"2012\" >2012<\/option>\r\n                                                            <option value=\"2011\" >2011<\/option>\r\n                                                            <option value=\"2010\" >2010<\/option>\r\n                                                            <option value=\"2009\" >2009<\/option>\r\n                                                            <option value=\"2008\" >2008<\/option>\r\n                                                            <option value=\"2007\" >2007<\/option>\r\n                                                            <option value=\"2006\" >2006<\/option>\r\n                                                            <option value=\"2005\" >2005<\/option>\r\n                                                            <option value=\"2004\" >2004<\/option>\r\n                                                            <option value=\"2003\" >2003<\/option>\r\n                                                            <option value=\"2002\" >2002<\/option>\r\n                                                            <option value=\"2001\" >2001<\/option>\r\n                                                            <option value=\"2000\" >2000<\/option>\r\n                                                            <option value=\"1999\" >1999<\/option>\r\n                                                            <option value=\"1998\" >1998<\/option>\r\n                                                            <option value=\"1997\" >1997<\/option>\r\n                                                            <option value=\"1996\" >1996<\/option>\r\n                                                            <option value=\"1995\" >1995<\/option>\r\n                                                            <option value=\"1994\" >1994<\/option>\r\n                                                            <option value=\"1993\" >1993<\/option>\r\n                                                            <option value=\"1992\" >1992<\/option>\r\n                                                            <option value=\"1991\" >1991<\/option>\r\n                                                            <option value=\"1990\" >1990<\/option>\r\n                                                            <option value=\"1989\" >1989<\/option>\r\n                                                            <option value=\"1988\" >1988<\/option>\r\n                                                            <option value=\"1987\" >1987<\/option>\r\n                                                            <option value=\"1986\" >1986<\/option>\r\n                                                            <option value=\"1985\" >1985<\/option>\r\n                                                            <option value=\"1984\" >1984<\/option>\r\n                                                            <option value=\"1983\" >1983<\/option>\r\n                                                            <option value=\"1982\" >1982<\/option>\r\n                                                            <option value=\"1981\" >1981<\/option>\r\n                                                            <option value=\"1980\" >1980<\/option>\r\n                                                            <option value=\"1979\" >1979<\/option>\r\n                                                            <option value=\"1978\" >1978<\/option>\r\n                                                            <option value=\"1977\" >1977<\/option>\r\n                                                            <option value=\"1976\" >1976<\/option>\r\n                                                            <option value=\"1975\" >1975<\/option>\r\n                                                            <option value=\"1974\" >1974<\/option>\r\n                                                            <option value=\"1973\" >1973<\/option>\r\n                                                            <option value=\"1972\" >1972<\/option>\r\n                                                            <option value=\"1971\" >1971<\/option>\r\n                                                            <option value=\"1970\" >1970<\/option>\r\n                                                            <option value=\"1969\" >1969<\/option>\r\n                                                            <option value=\"1968\" >1968<\/option>\r\n                                                            <option value=\"1967\" >1967<\/option>\r\n                                                            <option value=\"1966\" >1966<\/option>\r\n                                                            <option value=\"1965\" >1965<\/option>\r\n                                                            <option value=\"1964\" >1964<\/option>\r\n                                                            <option value=\"1963\" >1963<\/option>\r\n                                                            <option value=\"1962\" >1962<\/option>\r\n                                                            <option value=\"1961\" >1961<\/option>\r\n                                                            <option value=\"1960\" >1960<\/option>\r\n                                                            <option value=\"1959\" >1959<\/option>\r\n                                                            <option value=\"1958\" >1958<\/option>\r\n                                                            <option value=\"1957\" >1957<\/option>\r\n                                                            <option value=\"1956\" >1956<\/option>\r\n                                                            <option value=\"1955\" >1955<\/option>\r\n                                                            <option value=\"1954\" >1954<\/option>\r\n                                                            <option value=\"1953\" >1953<\/option>\r\n                                                            <option value=\"1952\" >1952<\/option>\r\n                                                            <option value=\"1951\" >1951<\/option>\r\n                                                            <option value=\"1950\" >1950<\/option>\r\n                                                            <option value=\"1949\" >1949<\/option>\r\n                                                            <option value=\"1948\" >1948<\/option>\r\n                                                            <option value=\"1947\" >1947<\/option>\r\n                                                            <option value=\"1946\" >1946<\/option>\r\n                                                            <option value=\"1945\" >1945<\/option>\r\n                                                            <option value=\"1944\" >1944<\/option>\r\n                                                            <option value=\"1943\" >1943<\/option>\r\n                                                            <option value=\"1942\" >1942<\/option>\r\n                                                            <option value=\"1941\" >1941<\/option>\r\n                                                            <option value=\"1940\" >1940<\/option>\r\n                                                            <option value=\"1939\" >1939<\/option>\r\n                                                            <option value=\"1938\" >1938<\/option>\r\n                                                            <option value=\"1937\" >1937<\/option>\r\n                                                            <option value=\"1936\" >1936<\/option>\r\n                                                            <option value=\"1935\" >1935<\/option>\r\n                                                            <option value=\"1934\" >1934<\/option>\r\n                                                            <option value=\"1933\" >1933<\/option>\r\n                                                            <option value=\"1932\" >1932<\/option>\r\n                                                            <option value=\"1931\" >1931<\/option>\r\n                                                            <option value=\"1930\" >1930<\/option>\r\n                                                            <option value=\"1929\" >1929<\/option>\r\n                                                            <option value=\"1928\" >1928<\/option>\r\n                                                            <option value=\"1927\" >1927<\/option>\r\n                                                            <option value=\"1926\" >1926<\/option>\r\n                                                            <option value=\"1925\" >1925<\/option>\r\n                                                            <option value=\"1924\" >1924<\/option>\r\n                                                            <option value=\"1923\" >1923<\/option>\r\n                                                            <option value=\"1922\" >1922<\/option>\r\n                                                            <option value=\"1921\" >1921<\/option>\r\n                                                            <option value=\"1920\" >1920<\/option>\r\n                                                            <option value=\"1919\" >1919<\/option>\r\n                                                            <option value=\"1918\" >1918<\/option>\r\n                                                            <option value=\"1917\" >1917<\/option>\r\n                                                            <option value=\"1916\" >1916<\/option>\r\n                                                            <option value=\"1915\" >1915<\/option>\r\n                                                            <option value=\"1914\" >1914<\/option>\r\n                                                            <option value=\"1913\" >1913<\/option>\r\n                                                            <option value=\"1912\" >1912<\/option>\r\n                                                            <option value=\"1911\" >1911<\/option>\r\n                                                            <option value=\"1910\" >1910<\/option>\r\n                                                            <option value=\"1909\" >1909<\/option>\r\n                                                            <option value=\"1908\" >1908<\/option>\r\n                                                            <option value=\"1907\" >1907<\/option>\r\n                                                            <option value=\"1906\" >1906<\/option>\r\n                                                            <option value=\"1905\" >1905<\/option>\r\n                                                            <option value=\"1904\" >1904<\/option>\r\n                                                            <option value=\"1903\" >1903<\/option>\r\n                                                            <option value=\"1902\" >1902<\/option>\r\n                                                            <option value=\"1901\" >1901<\/option>\r\n                                                            <option value=\"1900\" >1900<\/option>\r\n                                                                        <\/select>\r\n                <\/div>\r\n                            <\/div>\r\n                    <\/div>\r\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\r\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-time iphorm_5_5-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-time iphorm_5_5-element-spacer\">\n        <label id=\"iphorm_5_5_6acc3aa337628_time_label\" class=\"iphorm_5_5-outer-label\" >Exact time of birth (hours and minutes):<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-date iphorm_5_5-input-wrap\" >\n            <label id=\"iphorm_5_5_6acc3aa337628_hour_label\" class=\"iphorm-screen-reader-text\">Hour<\/label>\n            <select id=\"iphorm_5_5_6acc3aa337628_hour\"  name=\"iphorm_5_5[hour]\" class=\"iphorm_5_5-input-hour\" aria-labelledby=\"iphorm_5_5_6acc3aa337628_time_label iphorm_5_5_6acc3aa337628_hour_label\" >\n                <option value=\"\">HH<\/option>                                                                                    <option value=\"00\" >00<\/option>\n                                                                    <option value=\"01\" >01<\/option>\n                                                                    <option value=\"02\" >02<\/option>\n                                                                    <option value=\"03\" >03<\/option>\n                                                                    <option value=\"04\" >04<\/option>\n                                                                    <option value=\"05\" >05<\/option>\n                                                                    <option value=\"06\" >06<\/option>\n                                                                    <option value=\"07\" >07<\/option>\n                                                                    <option value=\"08\" >08<\/option>\n                                                                    <option value=\"09\" >09<\/option>\n                                                                    <option value=\"10\" >10<\/option>\n                                                                    <option value=\"11\" >11<\/option>\n                                                                    <option value=\"12\"  selected='selected'>12<\/option>\n                                                                    <option value=\"13\" >13<\/option>\n                                                                    <option value=\"14\" >14<\/option>\n                                                                    <option value=\"15\" >15<\/option>\n                                                                    <option value=\"16\" >16<\/option>\n                                                                    <option value=\"17\" >17<\/option>\n                                                                    <option value=\"18\" >18<\/option>\n                                                                    <option value=\"19\" >19<\/option>\n                                                                    <option value=\"20\" >20<\/option>\n                                                                    <option value=\"21\" >21<\/option>\n                                                                    <option value=\"22\" >22<\/option>\n                                                                    <option value=\"23\" >23<\/option>\n                                                <\/select>\n            <label id=\"iphorm_5_5_6acc3aa337628_minute_label\" class=\"iphorm-screen-reader-text\">Minute<\/label>\n            <select id=\"iphorm_5_5_6acc3aa337628_minute\" name=\"iphorm_5_5[minute]\" class=\"iphorm_5_5-input-minute\" aria-labelledby=\"iphorm_5_5_6acc3aa337628_time_label iphorm_5_5_6acc3aa337628_minute_label\" >\n                <option value=\"\">MM<\/option>                                                                                    <option value=\"00\"  selected='selected'>00<\/option>\n                                                                                                        <option value=\"01\" >01<\/option>\n                                                                                                        <option value=\"02\" >02<\/option>\n                                                                                                        <option value=\"03\" >03<\/option>\n                                                                                                        <option value=\"04\" >04<\/option>\n                                                                                                        <option value=\"05\" >05<\/option>\n                                                                                                        <option value=\"06\" >06<\/option>\n                                                                                                        <option value=\"07\" >07<\/option>\n                                                                                                        <option value=\"08\" >08<\/option>\n                                                                                                        <option value=\"09\" >09<\/option>\n                                                                                                        <option value=\"10\" >10<\/option>\n                                                                                                        <option value=\"11\" >11<\/option>\n                                                                                                        <option value=\"12\" >12<\/option>\n                                                                                                        <option value=\"13\" >13<\/option>\n                                                                                                        <option value=\"14\" >14<\/option>\n                                                                                                        <option value=\"15\" >15<\/option>\n                                                                                                        <option value=\"16\" >16<\/option>\n                                                                                                        <option value=\"17\" >17<\/option>\n                                                                                                        <option value=\"18\" >18<\/option>\n                                                                                                        <option value=\"19\" >19<\/option>\n                                                                                                        <option value=\"20\" >20<\/option>\n                                                                                                        <option value=\"21\" >21<\/option>\n                                                                                                        <option value=\"22\" >22<\/option>\n                                                                                                        <option value=\"23\" >23<\/option>\n                                                                                                        <option value=\"24\" >24<\/option>\n                                                                                                        <option value=\"25\" >25<\/option>\n                                                                                                        <option value=\"26\" >26<\/option>\n                                                                                                        <option value=\"27\" >27<\/option>\n                                                                                                        <option value=\"28\" >28<\/option>\n                                                                                                        <option value=\"29\" >29<\/option>\n                                                                                                        <option value=\"30\" >30<\/option>\n                                                                                                        <option value=\"31\" >31<\/option>\n                                                                                                        <option value=\"32\" >32<\/option>\n                                                                                                        <option value=\"33\" >33<\/option>\n                                                                                                        <option value=\"34\" >34<\/option>\n                                                                                                        <option value=\"35\" >35<\/option>\n                                                                                                        <option value=\"36\" >36<\/option>\n                                                                                                        <option value=\"37\" >37<\/option>\n                                                                                                        <option value=\"38\" >38<\/option>\n                                                                                                        <option value=\"39\" >39<\/option>\n                                                                                                        <option value=\"40\" >40<\/option>\n                                                                                                        <option value=\"41\" >41<\/option>\n                                                                                                        <option value=\"42\" >42<\/option>\n                                                                                                        <option value=\"43\" >43<\/option>\n                                                                                                        <option value=\"44\" >44<\/option>\n                                                                                                        <option value=\"45\" >45<\/option>\n                                                                                                        <option value=\"46\" >46<\/option>\n                                                                                                        <option value=\"47\" >47<\/option>\n                                                                                                        <option value=\"48\" >48<\/option>\n                                                                                                        <option value=\"49\" >49<\/option>\n                                                                                                        <option value=\"50\" >50<\/option>\n                                                                                                        <option value=\"51\" >51<\/option>\n                                                                                                        <option value=\"52\" >52<\/option>\n                                                                                                        <option value=\"53\" >53<\/option>\n                                                                                                        <option value=\"54\" >54<\/option>\n                                                                                                        <option value=\"55\" >55<\/option>\n                                                                                                        <option value=\"56\" >56<\/option>\n                                                                                                        <option value=\"57\" >57<\/option>\n                                                                                                        <option value=\"58\" >58<\/option>\n                                                                                                        <option value=\"59\" >59<\/option>\n                                                <\/select>\n                            <input type=\"hidden\" name=\"iphorm_5_5[ampm]\" value=\"\" \/>\n                                <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_6-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_6-element-spacer\">\n        <label class=\"iphorm_5_6-outer-label\" >If you don\u2019t know the exact time of birth, enter the approximate time and tick this box:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_6-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_6-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_6-input-li\" >\n                    <label for=\"iphorm_5_6_6acc3aa337628_1\"  class=\"iphorm_5_6_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_6 iphorm_5_6_1\" type=\"checkbox\" name=\"iphorm_5_6[]\" id=\"iphorm_5_6_6acc3aa337628_1\" value=\"I know the approximate time of birth only.\"  \/>\n                        I know the approximate time of birth only.                    <\/label>\n                <\/div>\n                        <\/div>\n                <p class=\"iphorm-description\" >Attention! If you don\u2019t know the exact time of birth, predictions may be inaccurate. The approximate time of birth can be stated for psychological and compatibility horoscopes. The more exact time of birth is stated, the more accurate the prediction is!<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_9-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_9-element-spacer\">\n        <label for=\"iphorm_5_9_6acc3aa337628\" class=\"iphorm_5_9-outer-label\" >Exact country of birth:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_9-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_9\" id=\"iphorm_5_9_6acc3aa337628\" type=\"text\" name=\"iphorm_5_9\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_10-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_10-element-spacer\">\n        <label for=\"iphorm_5_10_6acc3aa337628\" class=\"iphorm_5_10-outer-label\" >Exact city of birth:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_10-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_10\" id=\"iphorm_5_10_6acc3aa337628\" type=\"text\" name=\"iphorm_5_10\"  value=\"\"  \/>\n                <p class=\"iphorm-description\" >(If you were born in a small settlement, state the closest city.)<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_11-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_11-element-spacer\">\n        <label for=\"iphorm_5_11_6acc3aa337628\" class=\"iphorm_5_11-outer-label\" >Country where you live in now:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_11-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_11\" id=\"iphorm_5_11_6acc3aa337628\" type=\"text\" name=\"iphorm_5_11\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_12-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_12-element-spacer\">\n        <label for=\"iphorm_5_12_6acc3aa337628\" class=\"iphorm_5_12-outer-label\" >City where you live in now:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_12-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_12\" id=\"iphorm_5_12_6acc3aa337628\" type=\"text\" name=\"iphorm_5_12\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_13-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_13-element-spacer\">\n        <label class=\"iphorm_5_13-outer-label\" >Your education:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_13-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_13-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_13-input-li\" >\n                    <label for=\"iphorm_5_13_6acc3aa337628_1\"  class=\"iphorm_5_13_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_13 iphorm_5_13_1\" type=\"checkbox\" name=\"iphorm_5_13[]\" id=\"iphorm_5_13_6acc3aa337628_1\" value=\"Secondary\"  \/>\n                        Secondary                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_13-input-li\" >\n                    <label for=\"iphorm_5_13_6acc3aa337628_2\"  class=\"iphorm_5_13_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_13 iphorm_5_13_2\" type=\"checkbox\" name=\"iphorm_5_13[]\" id=\"iphorm_5_13_6acc3aa337628_2\" value=\"Secondary-special\"  \/>\n                        Secondary-special                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_13-input-li\" >\n                    <label for=\"iphorm_5_13_6acc3aa337628_3\"  class=\"iphorm_5_13_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_13 iphorm_5_13_3\" type=\"checkbox\" name=\"iphorm_5_13[]\" id=\"iphorm_5_13_6acc3aa337628_3\" value=\"Higher\"  \/>\n                        Higher                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_14-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_14-element-spacer\">\n        <label for=\"iphorm_5_14_6acc3aa337628\" class=\"iphorm_5_14-outer-label\" >State the speciality:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_14-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_14\" id=\"iphorm_5_14_6acc3aa337628\" type=\"text\" name=\"iphorm_5_14\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_15-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_15-element-spacer\">\n        <label class=\"iphorm_5_15-outer-label\" >Are you employed at the moment?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_15-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_15-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_15-input-li\" >\n                    <label for=\"iphorm_5_15_6acc3aa337628_1\"  class=\"iphorm_5_15_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_15 iphorm_5_15_1\" type=\"checkbox\" name=\"iphorm_5_15[]\" id=\"iphorm_5_15_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_15-input-li\" >\n                    <label for=\"iphorm_5_15_6acc3aa337628_2\"  class=\"iphorm_5_15_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_15 iphorm_5_15_2\" type=\"checkbox\" name=\"iphorm_5_15[]\" id=\"iphorm_5_15_6acc3aa337628_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_16-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_16-element-spacer\">\n        <label for=\"iphorm_5_16_6acc3aa337628\" class=\"iphorm_5_16-outer-label\" >Your profession<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_16-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_16\" id=\"iphorm_5_16_6acc3aa337628\" type=\"text\" name=\"iphorm_5_16\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_17-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_17-element-spacer\">\n        <label for=\"iphorm_5_17_6acc3aa337628\" class=\"iphorm_5_17-outer-label\" >Your hobbies:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_17-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_17\" id=\"iphorm_5_17_6acc3aa337628\" type=\"text\" name=\"iphorm_5_17\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_18-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_18-element-spacer\">\n        <label class=\"iphorm_5_18-outer-label\" >Marital status:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_18-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_18-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_18-input-li\" >\n                    <label for=\"iphorm_5_18_6acc3aa337628_1\"  class=\"iphorm_5_18_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_18 iphorm_5_18_1\" type=\"checkbox\" name=\"iphorm_5_18[]\" id=\"iphorm_5_18_6acc3aa337628_1\" value=\"Married\"  \/>\n                        Married                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_18-input-li\" >\n                    <label for=\"iphorm_5_18_6acc3aa337628_2\"  class=\"iphorm_5_18_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_18 iphorm_5_18_2\" type=\"checkbox\" name=\"iphorm_5_18[]\" id=\"iphorm_5_18_6acc3aa337628_2\" value=\"Single\"  \/>\n                        Single                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_18-input-li\" >\n                    <label for=\"iphorm_5_18_6acc3aa337628_3\"  class=\"iphorm_5_18_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_18 iphorm_5_18_3\" type=\"checkbox\" name=\"iphorm_5_18[]\" id=\"iphorm_5_18_6acc3aa337628_3\" value=\"Divorced\"  \/>\n                        Divorced                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_18-input-li\" >\n                    <label for=\"iphorm_5_18_6acc3aa337628_4\"  class=\"iphorm_5_18_4_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_18 iphorm_5_18_4\" type=\"checkbox\" name=\"iphorm_5_18[]\" id=\"iphorm_5_18_6acc3aa337628_4\" value=\"Widow(er)\"  \/>\n                        Widow(er)                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_19-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_19-element-spacer\">\n        <label class=\"iphorm_5_19-outer-label\" >Children<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_19-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_19-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_19-input-li\" >\n                    <label for=\"iphorm_5_19_6acc3aa337628_1\"  class=\"iphorm_5_19_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_19 iphorm_5_19_1\" type=\"checkbox\" name=\"iphorm_5_19[]\" id=\"iphorm_5_19_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_19-input-li\" >\n                    <label for=\"iphorm_5_19_6acc3aa337628_2\"  class=\"iphorm_5_19_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_19 iphorm_5_19_2\" type=\"checkbox\" name=\"iphorm_5_19[]\" id=\"iphorm_5_19_6acc3aa337628_2\" value=\"None\"  \/>\n                        None                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_20-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_20-element-spacer\">\n        <label for=\"iphorm_5_20_6acc3aa337628\" class=\"iphorm_5_20-outer-label\" >Number of children<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_20-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_20\" id=\"iphorm_5_20_6acc3aa337628\" type=\"text\" name=\"iphorm_5_20\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-textarea iphorm_5_34-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-textarea iphorm_5_34-element-spacer\">\n        <label for=\"iphorm_5_34_6acc3aa337628\" class=\"iphorm_5_34-outer-label\" >What serious diseases have you experienced and at what age:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-textarea iphorm_5_34-input-wrap\" >\n            <textarea class=\"iphorm-element-textarea  iphorm_5_34\" id=\"iphorm_5_34_6acc3aa337628\" name=\"iphorm_5_34\"   rows=\"5\" cols=\"25\"><\/textarea>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_35-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_35-element-spacer\">\n        <label class=\"iphorm_5_35-outer-label\" >Do you have any allergies?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_35-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_35-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_35-input-li\" >\n                    <label for=\"iphorm_5_35_6acc3aa337628_1\"  class=\"iphorm_5_35_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_35 iphorm_5_35_1\" type=\"checkbox\" name=\"iphorm_5_35[]\" id=\"iphorm_5_35_6acc3aa337628_1\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_35-input-li\" >\n                    <label for=\"iphorm_5_35_6acc3aa337628_2\"  class=\"iphorm_5_35_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_35 iphorm_5_35_2\" type=\"checkbox\" name=\"iphorm_5_35[]\" id=\"iphorm_5_35_6acc3aa337628_2\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_36-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_36-element-spacer\">\n        <label for=\"iphorm_5_36_6acc3aa337628\" class=\"iphorm_5_36-outer-label\" >What are you allergic to?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_36-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_36\" id=\"iphorm_5_36_6acc3aa337628\" type=\"text\" name=\"iphorm_5_36\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_37-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_37-element-spacer\">\n        <label for=\"iphorm_5_37_6acc3aa337628\" class=\"iphorm_5_37-outer-label\" >Since what age have you been allergic?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_37-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_37\" id=\"iphorm_5_37_6acc3aa337628\" type=\"text\" name=\"iphorm_5_37\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_38-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_38-element-spacer\">\n        <label class=\"iphorm_5_38-outer-label\" >Do you smoke?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_38-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_38-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_38-input-li\" >\n                    <label for=\"iphorm_5_38_6acc3aa337628_1\"  class=\"iphorm_5_38_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_38 iphorm_5_38_1\" type=\"checkbox\" name=\"iphorm_5_38[]\" id=\"iphorm_5_38_6acc3aa337628_1\" value=\"Often\"  \/>\n                        Often                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_38-input-li\" >\n                    <label for=\"iphorm_5_38_6acc3aa337628_2\"  class=\"iphorm_5_38_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_38 iphorm_5_38_2\" type=\"checkbox\" name=\"iphorm_5_38[]\" id=\"iphorm_5_38_6acc3aa337628_2\" value=\"Sometimes\"  \/>\n                        Sometimes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_38-input-li\" >\n                    <label for=\"iphorm_5_38_6acc3aa337628_3\"  class=\"iphorm_5_38_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_38 iphorm_5_38_3\" type=\"checkbox\" name=\"iphorm_5_38[]\" id=\"iphorm_5_38_6acc3aa337628_3\" value=\"I don\u2019t smoke\"  \/>\n                        I don\u2019t smoke                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_39-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_39-element-spacer\">\n        <label class=\"iphorm_5_39-outer-label\" >You consume alcohol:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_39-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_39-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_39-input-li\" >\n                    <label for=\"iphorm_5_39_6acc3aa337628_1\"  class=\"iphorm_5_39_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_39 iphorm_5_39_1\" type=\"checkbox\" name=\"iphorm_5_39[]\" id=\"iphorm_5_39_6acc3aa337628_1\" value=\"Often\"  \/>\n                        Often                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_39-input-li\" >\n                    <label for=\"iphorm_5_39_6acc3aa337628_2\"  class=\"iphorm_5_39_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_39 iphorm_5_39_2\" type=\"checkbox\" name=\"iphorm_5_39[]\" id=\"iphorm_5_39_6acc3aa337628_2\" value=\"Sometimes\"  \/>\n                        Sometimes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_39-input-li\" >\n                    <label for=\"iphorm_5_39_6acc3aa337628_3\"  class=\"iphorm_5_39_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_39 iphorm_5_39_3\" type=\"checkbox\" name=\"iphorm_5_39[]\" id=\"iphorm_5_39_6acc3aa337628_3\" value=\"I don\u2019t consume alcohol\"  \/>\n                        I don\u2019t consume alcohol                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_40-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_40-element-spacer\">\n        <label class=\"iphorm_5_40-outer-label\" >You drink milk:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_40-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_40-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_40-input-li\" >\n                    <label for=\"iphorm_5_40_6acc3aa337628_1\"  class=\"iphorm_5_40_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_40 iphorm_5_40_1\" type=\"checkbox\" name=\"iphorm_5_40[]\" id=\"iphorm_5_40_6acc3aa337628_1\" value=\"Often\"  \/>\n                        Often                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_40-input-li\" >\n                    <label for=\"iphorm_5_40_6acc3aa337628_2\"  class=\"iphorm_5_40_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_40 iphorm_5_40_2\" type=\"checkbox\" name=\"iphorm_5_40[]\" id=\"iphorm_5_40_6acc3aa337628_2\" value=\"Sometimes\"  \/>\n                        Sometimes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_40-input-li\" >\n                    <label for=\"iphorm_5_40_6acc3aa337628_3\"  class=\"iphorm_5_40_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_40 iphorm_5_40_3\" type=\"checkbox\" name=\"iphorm_5_40[]\" id=\"iphorm_5_40_6acc3aa337628_3\" value=\"I don\u2019t drink milk\"  \/>\n                        I don\u2019t drink milk                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_41-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_41-element-spacer\">\n        <label class=\"iphorm_5_41-outer-label\" >You use the following more frequently:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_41-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_41-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_41-input-li\" >\n                    <label for=\"iphorm_5_41_6acc3aa337628_1\"  class=\"iphorm_5_41_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_41 iphorm_5_41_1\" type=\"checkbox\" name=\"iphorm_5_41[]\" id=\"iphorm_5_41_6acc3aa337628_1\" value=\"Shower\"  \/>\n                        Shower                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_41-input-li\" >\n                    <label for=\"iphorm_5_41_6acc3aa337628_2\"  class=\"iphorm_5_41_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_41 iphorm_5_41_2\" type=\"checkbox\" name=\"iphorm_5_41[]\" id=\"iphorm_5_41_6acc3aa337628_2\" value=\"Bath\"  \/>\n                        Bath                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_42-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_42-element-spacer\">\n        <label class=\"iphorm_5_42-outer-label\" >You use sugar and products thereof (sweets, etc.):<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_42-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_42-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_42-input-li\" >\n                    <label for=\"iphorm_5_42_6acc3aa337628_1\"  class=\"iphorm_5_42_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_42 iphorm_5_42_1\" type=\"checkbox\" name=\"iphorm_5_42[]\" id=\"iphorm_5_42_6acc3aa337628_1\" value=\"A lot\"  \/>\n                        A lot                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_42-input-li\" >\n                    <label for=\"iphorm_5_42_6acc3aa337628_2\"  class=\"iphorm_5_42_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_42 iphorm_5_42_2\" type=\"checkbox\" name=\"iphorm_5_42[]\" id=\"iphorm_5_42_6acc3aa337628_2\" value=\"Little\"  \/>\n                        Little                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_43-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_43-element-spacer\">\n        <label class=\"iphorm_5_43-outer-label\" >Are you a vegetarian?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_43-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_43-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_43-input-li\" >\n                    <label for=\"iphorm_5_43_6acc3aa337628_1\"  class=\"iphorm_5_43_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_43 iphorm_5_43_1\" type=\"checkbox\" name=\"iphorm_5_43[]\" id=\"iphorm_5_43_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_43-input-li\" >\n                    <label for=\"iphorm_5_43_6acc3aa337628_2\"  class=\"iphorm_5_43_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_43 iphorm_5_43_2\" type=\"checkbox\" name=\"iphorm_5_43[]\" id=\"iphorm_5_43_6acc3aa337628_2\" value=\"I don\u2019t eat much meat\"  \/>\n                        I don\u2019t eat much meat                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_43-input-li\" >\n                    <label for=\"iphorm_5_43_6acc3aa337628_3\"  class=\"iphorm_5_43_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_43 iphorm_5_43_3\" type=\"checkbox\" name=\"iphorm_5_43[]\" id=\"iphorm_5_43_6acc3aa337628_3\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_44-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_44-element-spacer\">\n        <label class=\"iphorm_5_44-outer-label\" >Do you constantly use medical preparations?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_44-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_44-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_44-input-li\" >\n                    <label for=\"iphorm_5_44_6acc3aa337628_1\"  class=\"iphorm_5_44_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_44 iphorm_5_44_1\" type=\"checkbox\" name=\"iphorm_5_44[]\" id=\"iphorm_5_44_6acc3aa337628_1\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_44-input-li\" >\n                    <label for=\"iphorm_5_44_6acc3aa337628_2\"  class=\"iphorm_5_44_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_44 iphorm_5_44_2\" type=\"checkbox\" name=\"iphorm_5_44[]\" id=\"iphorm_5_44_6acc3aa337628_2\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_45-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_45-element-spacer\">\n        <label for=\"iphorm_5_45_6acc3aa337628\" class=\"iphorm_5_45-outer-label\" >What kind?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_45-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_45\" id=\"iphorm_5_45_6acc3aa337628\" type=\"text\" name=\"iphorm_5_45\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_46-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_46-element-spacer\">\n        <label class=\"iphorm_5_46-outer-label\" >Do you use food supplements and vitamins?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_46-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_46-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_46-input-li\" >\n                    <label for=\"iphorm_5_46_6acc3aa337628_1\"  class=\"iphorm_5_46_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_46 iphorm_5_46_1\" type=\"checkbox\" name=\"iphorm_5_46[]\" id=\"iphorm_5_46_6acc3aa337628_1\" value=\"Often\"  \/>\n                        Often                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_46-input-li\" >\n                    <label for=\"iphorm_5_46_6acc3aa337628_2\"  class=\"iphorm_5_46_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_46 iphorm_5_46_2\" type=\"checkbox\" name=\"iphorm_5_46[]\" id=\"iphorm_5_46_6acc3aa337628_2\" value=\"Seldom\"  \/>\n                        Seldom                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_46-input-li\" >\n                    <label for=\"iphorm_5_46_6acc3aa337628_3\"  class=\"iphorm_5_46_3_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_46 iphorm_5_46_3\" type=\"checkbox\" name=\"iphorm_5_46[]\" id=\"iphorm_5_46_6acc3aa337628_3\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_47-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_47-element-spacer\">\n        <label for=\"iphorm_5_47_6acc3aa337628\" class=\"iphorm_5_47-outer-label\" >What supplements do you use?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_47-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_47\" id=\"iphorm_5_47_6acc3aa337628\" type=\"text\" name=\"iphorm_5_47\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_48-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_48-element-spacer\">\n        <label for=\"iphorm_5_48_6acc3aa337628\" class=\"iphorm_5_48-outer-label\" >Your height:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_48-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_48\" id=\"iphorm_5_48_6acc3aa337628\" type=\"text\" name=\"iphorm_5_48\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_49-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_49-element-spacer\">\n        <label for=\"iphorm_5_49_6acc3aa337628\" class=\"iphorm_5_49-outer-label\" >Your weight:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_49-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_49\" id=\"iphorm_5_49_6acc3aa337628\" type=\"text\" name=\"iphorm_5_49\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_80-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_80-element-spacer\">\n        <label class=\"iphorm_5_80-outer-label\" >Do you have any sight issues?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_80-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_80-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_80-input-li\" >\n                    <label for=\"iphorm_5_80_6acc3aa337628_1\"  class=\"iphorm_5_80_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_80 iphorm_5_80_1\" type=\"checkbox\" name=\"iphorm_5_80[]\" id=\"iphorm_5_80_6acc3aa337628_1\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_80-input-li\" >\n                    <label for=\"iphorm_5_80_6acc3aa337628_2\"  class=\"iphorm_5_80_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_80 iphorm_5_80_2\" type=\"checkbox\" name=\"iphorm_5_80[]\" id=\"iphorm_5_80_6acc3aa337628_2\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_81-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_81-element-spacer\">\n        <label for=\"iphorm_5_81_6acc3aa337628\" class=\"iphorm_5_81-outer-label\" >What kind?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_81-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_81\" id=\"iphorm_5_81_6acc3aa337628\" type=\"text\" name=\"iphorm_5_81\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_82-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_82-element-spacer\">\n        <label class=\"iphorm_5_82-outer-label\" >Must you wear glasses constantly?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_82-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_82-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_82-input-li\" >\n                    <label for=\"iphorm_5_82_6acc3aa337628_1\"  class=\"iphorm_5_82_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_82 iphorm_5_82_1\" type=\"checkbox\" name=\"iphorm_5_82[]\" id=\"iphorm_5_82_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_82-input-li\" >\n                    <label for=\"iphorm_5_82_6acc3aa337628_2\"  class=\"iphorm_5_82_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_82 iphorm_5_82_2\" type=\"checkbox\" name=\"iphorm_5_82[]\" id=\"iphorm_5_82_6acc3aa337628_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div>You have been or are ill with the following diseases (if yes, write in the additional box when that happened and how often the disease recurs):<div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_51-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_51-element-spacer\">\n        <label class=\"iphorm_5_51-outer-label\" >Heart disease:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_51-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_51-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_51-input-li\" >\n                    <label for=\"iphorm_5_51_6acc3aa337628_1\"  class=\"iphorm_5_51_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_51 iphorm_5_51_1\" type=\"checkbox\" name=\"iphorm_5_51[]\" id=\"iphorm_5_51_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_51-input-li\" >\n                    <label for=\"iphorm_5_51_6acc3aa337628_2\"  class=\"iphorm_5_51_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_51 iphorm_5_51_2\" type=\"checkbox\" name=\"iphorm_5_51[]\" id=\"iphorm_5_51_6acc3aa337628_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_52-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_52-element-spacer\">\n        <label for=\"iphorm_5_52_6acc3aa337628\" class=\"iphorm_5_52-outer-label\" >When did you have a heart disease and how often does it recur?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_52-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_52\" id=\"iphorm_5_52_6acc3aa337628\" type=\"text\" name=\"iphorm_5_52\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_53-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_53-element-spacer\">\n        <label class=\"iphorm_5_53-outer-label\" >Blood disease:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_53-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_53-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_53-input-li\" >\n                    <label for=\"iphorm_5_53_6acc3aa337628_1\"  class=\"iphorm_5_53_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_53 iphorm_5_53_1\" type=\"checkbox\" name=\"iphorm_5_53[]\" id=\"iphorm_5_53_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_53-input-li\" >\n                    <label for=\"iphorm_5_53_6acc3aa337628_2\"  class=\"iphorm_5_53_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_53 iphorm_5_53_2\" type=\"checkbox\" name=\"iphorm_5_53[]\" id=\"iphorm_5_53_6acc3aa337628_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_54-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_54-element-spacer\">\n        <label for=\"iphorm_5_54_6acc3aa337628\" class=\"iphorm_5_54-outer-label\" >When did you have a blood disease and how often does it recur?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_54-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_54\" id=\"iphorm_5_54_6acc3aa337628\" type=\"text\" name=\"iphorm_5_54\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_55-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_55-element-spacer\">\n        <label class=\"iphorm_5_55-outer-label\" >Headaches:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_55-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_55-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_55-input-li\" >\n                    <label for=\"iphorm_5_55_6acc3aa337628_1\"  class=\"iphorm_5_55_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_55 iphorm_5_55_1\" type=\"checkbox\" name=\"iphorm_5_55[]\" id=\"iphorm_5_55_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_55-input-li\" >\n                    <label for=\"iphorm_5_55_6acc3aa337628_2\"  class=\"iphorm_5_55_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_55 iphorm_5_55_2\" type=\"checkbox\" name=\"iphorm_5_55[]\" id=\"iphorm_5_55_6acc3aa337628_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_56-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_56-element-spacer\">\n        <label for=\"iphorm_5_56_6acc3aa337628\" class=\"iphorm_5_56-outer-label\" >When did you have headaches and how often do they recur?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_56-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_56\" id=\"iphorm_5_56_6acc3aa337628\" type=\"text\" name=\"iphorm_5_56\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_57-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_57-element-spacer\">\n        <label class=\"iphorm_5_57-outer-label\" >Dizziness:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_57-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_57-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_57-input-li\" >\n                    <label for=\"iphorm_5_57_6acc3aa337628_1\"  class=\"iphorm_5_57_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_57 iphorm_5_57_1\" type=\"checkbox\" name=\"iphorm_5_57[]\" id=\"iphorm_5_57_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_57-input-li\" >\n                    <label for=\"iphorm_5_57_6acc3aa337628_2\"  class=\"iphorm_5_57_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_57 iphorm_5_57_2\" type=\"checkbox\" name=\"iphorm_5_57[]\" id=\"iphorm_5_57_6acc3aa337628_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_58-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_58-element-spacer\">\n        <label for=\"iphorm_5_58_6acc3aa337628\" class=\"iphorm_5_58-outer-label\" >When did you have dizziness and how often does it recur?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_58-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_58\" id=\"iphorm_5_58_6acc3aa337628\" type=\"text\" name=\"iphorm_5_58\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_59-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_59-element-spacer\">\n        <label class=\"iphorm_5_59-outer-label\" >Gland issues:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_59-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_59-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_59-input-li\" >\n                    <label for=\"iphorm_5_59_6acc3aa337628_1\"  class=\"iphorm_5_59_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_59 iphorm_5_59_1\" type=\"checkbox\" name=\"iphorm_5_59[]\" id=\"iphorm_5_59_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_59-input-li\" >\n                    <label for=\"iphorm_5_59_6acc3aa337628_2\"  class=\"iphorm_5_59_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_59 iphorm_5_59_2\" type=\"checkbox\" name=\"iphorm_5_59[]\" id=\"iphorm_5_59_6acc3aa337628_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_60-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_60-element-spacer\">\n        <label for=\"iphorm_5_60_6acc3aa337628\" class=\"iphorm_5_60-outer-label\" >Specify the gland:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_60-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_60\" id=\"iphorm_5_60_6acc3aa337628\" type=\"text\" name=\"iphorm_5_60\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_61-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_61-element-spacer\">\n        <label class=\"iphorm_5_61-outer-label\" >High blood pressure:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_61-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_61-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_61-input-li\" >\n                    <label for=\"iphorm_5_61_6acc3aa337628_1\"  class=\"iphorm_5_61_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_61 iphorm_5_61_1\" type=\"checkbox\" name=\"iphorm_5_61[]\" id=\"iphorm_5_61_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_61-input-li\" >\n                    <label for=\"iphorm_5_61_6acc3aa337628_2\"  class=\"iphorm_5_61_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_61 iphorm_5_61_2\" type=\"checkbox\" name=\"iphorm_5_61[]\" id=\"iphorm_5_61_6acc3aa337628_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_62-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_62-element-spacer\">\n        <label for=\"iphorm_5_62_6acc3aa337628\" class=\"iphorm_5_62-outer-label\" >When did you have blood pressure issues and how often do they recur?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_62-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_62\" id=\"iphorm_5_62_6acc3aa337628\" type=\"text\" name=\"iphorm_5_62\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_63-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_63-element-spacer\">\n        <label class=\"iphorm_5_63-outer-label\" >Liver disease:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_63-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_63-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_63-input-li\" >\n                    <label for=\"iphorm_5_63_6acc3aa337628_1\"  class=\"iphorm_5_63_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_63 iphorm_5_63_1\" type=\"checkbox\" name=\"iphorm_5_63[]\" id=\"iphorm_5_63_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_63-input-li\" >\n                    <label for=\"iphorm_5_63_6acc3aa337628_2\"  class=\"iphorm_5_63_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_63 iphorm_5_63_2\" type=\"checkbox\" name=\"iphorm_5_63[]\" id=\"iphorm_5_63_6acc3aa337628_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_64-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_64-element-spacer\">\n        <label for=\"iphorm_5_64_6acc3aa337628\" class=\"iphorm_5_64-outer-label\" >When did you have a liver disease and how often does it recur?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_64-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_64\" id=\"iphorm_5_64_6acc3aa337628\" type=\"text\" name=\"iphorm_5_64\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_65-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_65-element-spacer\">\n        <label class=\"iphorm_5_65-outer-label\" >Kidney disease:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_65-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_65-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_65-input-li\" >\n                    <label for=\"iphorm_5_65_6acc3aa337628_1\"  class=\"iphorm_5_65_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_65 iphorm_5_65_1\" type=\"checkbox\" name=\"iphorm_5_65[]\" id=\"iphorm_5_65_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_65-input-li\" >\n                    <label for=\"iphorm_5_65_6acc3aa337628_2\"  class=\"iphorm_5_65_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_65 iphorm_5_65_2\" type=\"checkbox\" name=\"iphorm_5_65[]\" id=\"iphorm_5_65_6acc3aa337628_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_66-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_66-element-spacer\">\n        <label for=\"iphorm_5_66_6acc3aa337628\" class=\"iphorm_5_66-outer-label\" >When did you have a kidney disease and how often does it recur?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_66-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_66\" id=\"iphorm_5_66_6acc3aa337628\" type=\"text\" name=\"iphorm_5_66\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_67-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_67-element-spacer\">\n        <label class=\"iphorm_5_67-outer-label\" >Irritated nerves:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_67-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_67-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_67-input-li\" >\n                    <label for=\"iphorm_5_67_6acc3aa337628_1\"  class=\"iphorm_5_67_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_67 iphorm_5_67_1\" type=\"checkbox\" name=\"iphorm_5_67[]\" id=\"iphorm_5_67_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_67-input-li\" >\n                    <label for=\"iphorm_5_67_6acc3aa337628_2\"  class=\"iphorm_5_67_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_67 iphorm_5_67_2\" type=\"checkbox\" name=\"iphorm_5_67[]\" id=\"iphorm_5_67_6acc3aa337628_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_68-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_68-element-spacer\">\n        <label for=\"iphorm_5_68_6acc3aa337628\" class=\"iphorm_5_68-outer-label\" >When did you have irritated nerves and how often does that recur?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_68-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_68\" id=\"iphorm_5_68_6acc3aa337628\" type=\"text\" name=\"iphorm_5_68\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_69-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_69-element-spacer\">\n        <label class=\"iphorm_5_69-outer-label\" >Stomach disease:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_69-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_69-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_69-input-li\" >\n                    <label for=\"iphorm_5_69_6acc3aa337628_1\"  class=\"iphorm_5_69_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_69 iphorm_5_69_1\" type=\"checkbox\" name=\"iphorm_5_69[]\" id=\"iphorm_5_69_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_69-input-li\" >\n                    <label for=\"iphorm_5_69_6acc3aa337628_2\"  class=\"iphorm_5_69_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_69 iphorm_5_69_2\" type=\"checkbox\" name=\"iphorm_5_69[]\" id=\"iphorm_5_69_6acc3aa337628_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_70-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_70-element-spacer\">\n        <label for=\"iphorm_5_70_6acc3aa337628\" class=\"iphorm_5_70-outer-label\" >When did you have a stomach disease and how often does it recur?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_70-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_70\" id=\"iphorm_5_70_6acc3aa337628\" type=\"text\" name=\"iphorm_5_70\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_71-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_71-element-spacer\">\n        <label class=\"iphorm_5_71-outer-label\" >Disorders of the menstrual cycle (*for females):<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_71-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_71-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_71-input-li\" >\n                    <label for=\"iphorm_5_71_6acc3aa337628_1\"  class=\"iphorm_5_71_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_71 iphorm_5_71_1\" type=\"checkbox\" name=\"iphorm_5_71[]\" id=\"iphorm_5_71_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_71-input-li\" >\n                    <label for=\"iphorm_5_71_6acc3aa337628_2\"  class=\"iphorm_5_71_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_71 iphorm_5_71_2\" type=\"checkbox\" name=\"iphorm_5_71[]\" id=\"iphorm_5_71_6acc3aa337628_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_72-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_72-element-spacer\">\n        <label for=\"iphorm_5_72_6acc3aa337628\" class=\"iphorm_5_72-outer-label\" >When did you experience any disorders of the menstrual cycle and how often do they recur?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_72-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_72\" id=\"iphorm_5_72_6acc3aa337628\" type=\"text\" name=\"iphorm_5_72\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_73-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_73-element-spacer\">\n        <label class=\"iphorm_5_73-outer-label\" >Do you have any chronic diseases?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_73-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_73-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_73-input-li\" >\n                    <label for=\"iphorm_5_73_6acc3aa337628_1\"  class=\"iphorm_5_73_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_73 iphorm_5_73_1\" type=\"checkbox\" name=\"iphorm_5_73[]\" id=\"iphorm_5_73_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_73-input-li\" >\n                    <label for=\"iphorm_5_73_6acc3aa337628_2\"  class=\"iphorm_5_73_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_73 iphorm_5_73_2\" type=\"checkbox\" name=\"iphorm_5_73[]\" id=\"iphorm_5_73_6acc3aa337628_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_74-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_74-element-spacer\">\n        <label for=\"iphorm_5_74_6acc3aa337628\" class=\"iphorm_5_74-outer-label\" >What chronic diseases do you have and how often do they recur?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_74-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_74\" id=\"iphorm_5_74_6acc3aa337628\" type=\"text\" name=\"iphorm_5_74\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_75-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_75-element-spacer\">\n        <label class=\"iphorm_5_75-outer-label\" >Have you ever undergone surgery?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_75-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_75-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_75-input-li\" >\n                    <label for=\"iphorm_5_75_6acc3aa337628_1\"  class=\"iphorm_5_75_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_75 iphorm_5_75_1\" type=\"checkbox\" name=\"iphorm_5_75[]\" id=\"iphorm_5_75_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_75-input-li\" >\n                    <label for=\"iphorm_5_75_6acc3aa337628_2\"  class=\"iphorm_5_75_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_75 iphorm_5_75_2\" type=\"checkbox\" name=\"iphorm_5_75[]\" id=\"iphorm_5_75_6acc3aa337628_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_76-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_76-element-spacer\">\n        <label for=\"iphorm_5_76_6acc3aa337628\" class=\"iphorm_5_76-outer-label\" >When did you undergo surgery and what was the reason of the surgery?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_76-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_76\" id=\"iphorm_5_76_6acc3aa337628\" type=\"text\" name=\"iphorm_5_76\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_77-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_77-element-spacer\">\n        <label class=\"iphorm_5_77-outer-label\" >Have you ever experienced any physical injuries?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_77-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_77-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_77-input-li\" >\n                    <label for=\"iphorm_5_77_6acc3aa337628_1\"  class=\"iphorm_5_77_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_77 iphorm_5_77_1\" type=\"checkbox\" name=\"iphorm_5_77[]\" id=\"iphorm_5_77_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_77-input-li\" >\n                    <label for=\"iphorm_5_77_6acc3aa337628_2\"  class=\"iphorm_5_77_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_77 iphorm_5_77_2\" type=\"checkbox\" name=\"iphorm_5_77[]\" id=\"iphorm_5_77_6acc3aa337628_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_78-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_78-element-spacer\">\n        <label for=\"iphorm_5_78_6acc3aa337628\" class=\"iphorm_5_78-outer-label\" >What physical injuries did you experience and when?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_78-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_78\" id=\"iphorm_5_78_6acc3aa337628\" type=\"text\" name=\"iphorm_5_78\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-textarea iphorm_5_21-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-textarea iphorm_5_21-element-spacer\">\n        <label for=\"iphorm_5_21_6acc3aa337628\" class=\"iphorm_5_21-outer-label\" >You can write down the specific issues you are interested in or what specifically the astrologer should take into account when analyzing the Horoscope:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-textarea iphorm_5_21-input-wrap\" >\n            <textarea class=\"iphorm-element-textarea  iphorm_5_21\" id=\"iphorm_5_21_6acc3aa337628\" name=\"iphorm_5_21\"   rows=\"5\" cols=\"25\"><\/textarea>\n                <p class=\"iphorm-description\" >The clearer and more specific you formulate the questions and issues you are interested in, the more accurately we will be able to present information to you on the basis of your horoscope.<\/p>\n        <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_22-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_22-element-spacer\">\n        <label class=\"iphorm_5_22-outer-label\" >May we contact you should the astrologer have any questions regarding more specific data?<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_22-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_22-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_22-input-li\" >\n                    <label for=\"iphorm_5_22_6acc3aa337628_1\"  class=\"iphorm_5_22_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_22 iphorm_5_22_1\" type=\"checkbox\" name=\"iphorm_5_22[]\" id=\"iphorm_5_22_6acc3aa337628_1\" value=\"Yes\"  \/>\n                        Yes                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_22-input-li\" >\n                    <label for=\"iphorm_5_22_6acc3aa337628_2\"  class=\"iphorm_5_22_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_22 iphorm_5_22_2\" type=\"checkbox\" name=\"iphorm_5_22[]\" id=\"iphorm_5_22_6acc3aa337628_2\" value=\"No\"  \/>\n                        No                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_23-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_23-element-spacer\">\n        <label for=\"iphorm_5_23_6acc3aa337628\" class=\"iphorm_5_23-outer-label\" >Telephone number:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_23-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_23\" id=\"iphorm_5_23_6acc3aa337628\" type=\"text\" name=\"iphorm_5_23\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_24-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_24-element-spacer\">\n        <label for=\"iphorm_5_24_6acc3aa337628\" class=\"iphorm_5_24-outer-label\" >E-mail:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_24-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_24\" id=\"iphorm_5_24_6acc3aa337628\" type=\"text\" name=\"iphorm_5_24\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_25-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_25-element-spacer\">\n        <label class=\"iphorm_5_25-outer-label\" >Please state in which way you wish to receive the Horoscope you have ordered in a written form:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_25-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_25-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_25-input-li\" >\n                    <label for=\"iphorm_5_25_6acc3aa337628_1\"  class=\"iphorm_5_25_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_25 iphorm_5_25_1\" type=\"checkbox\" name=\"iphorm_5_25[]\" id=\"iphorm_5_25_6acc3aa337628_1\" value=\"By e-mail\"  \/>\n                        By e-mail                    <\/label>\n                <\/div>\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_25-input-li\" >\n                    <label for=\"iphorm_5_25_6acc3aa337628_2\"  class=\"iphorm_5_25_2_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_25 iphorm_5_25_2\" type=\"checkbox\" name=\"iphorm_5_25[]\" id=\"iphorm_5_25_6acc3aa337628_2\" value=\"By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)\"  \/>\n                        By ordinary mail (the Horoscope will be sent by registered mail at the address stated by you)                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_26-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_26-element-spacer\">\n        <label for=\"iphorm_5_26_6acc3aa337628\" class=\"iphorm_5_26-outer-label\" >State e-mail address at which you wish to receive the horoscope in a written form:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_26-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_26\" id=\"iphorm_5_26_6acc3aa337628\" type=\"text\" name=\"iphorm_5_26\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-html iphorm_5_28-element-wrap iphorm-clearfix\">\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-html iphorm_5_28-element-spacer\">\n        Please state your exact address at which we could send the Horoscope:    <\/div>\n<\/div>\n<div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_27-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_27-element-spacer\">\n        <label for=\"iphorm_5_27_6acc3aa337628\" class=\"iphorm_5_27-outer-label\" >Country:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_27-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_27\" id=\"iphorm_5_27_6acc3aa337628\" type=\"text\" name=\"iphorm_5_27\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_29-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_29-element-spacer\">\n        <label for=\"iphorm_5_29_6acc3aa337628\" class=\"iphorm_5_29-outer-label\" >City:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_29-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_29\" id=\"iphorm_5_29_6acc3aa337628\" type=\"text\" name=\"iphorm_5_29\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_30-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_30-element-spacer\">\n        <label for=\"iphorm_5_30_6acc3aa337628\" class=\"iphorm_5_30-outer-label\" >Street:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_30-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_30\" id=\"iphorm_5_30_6acc3aa337628\" type=\"text\" name=\"iphorm_5_30\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_31-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_31-element-spacer\">\n        <label for=\"iphorm_5_31_6acc3aa337628\" class=\"iphorm_5_31-outer-label\" >House:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_31-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_31\" id=\"iphorm_5_31_6acc3aa337628\" type=\"text\" name=\"iphorm_5_31\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-text iphorm_5_32-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-text iphorm_5_32-element-spacer\">\n        <label for=\"iphorm_5_32_6acc3aa337628\" class=\"iphorm_5_32-outer-label\" >Apartment:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-text iphorm_5_32-input-wrap\" >\n            <input class=\"iphorm-element-text  iphorm_5_32\" id=\"iphorm_5_32_6acc3aa337628\" type=\"text\" name=\"iphorm_5_32\"  value=\"\"  \/>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n    <\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-checkbox iphorm_5_33-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-optional\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-checkbox iphorm_5_33-element-spacer\">\n        <label class=\"iphorm_5_33-outer-label\" >Order confirmation:<\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-checkbox iphorm_5_33-input-wrap\" >\n            <div class=\"iphorm-input-ul iphorm-input-checkbox-ul iphorm_5_33-input-ul iphorm-options-block iphorm-clearfix\" >\n                            <div class=\"iphorm-input-li iphorm-input-checkbox-li iphorm_5_33-input-li\" >\n                    <label for=\"iphorm_5_33_6acc3aa337628_1\"  class=\"iphorm_5_33_1_label\">\n                        <input class=\"iphorm-element-checkbox iphorm_5_33 iphorm_5_33_1\" type=\"checkbox\" name=\"iphorm_5_33[]\" id=\"iphorm_5_33_6acc3aa337628_1\" value=\"I order a horoscope and guarantee that the data presented in the registration form is true.\"  \/>\n                        I order a horoscope and guarantee that the data presented in the registration form is true.                    <\/label>\n                <\/div>\n                        <\/div>\n                    <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-element-wrap iphorm-element-wrap-recaptcha g-recaptcha-response-element-wrap iphorm_5_84-element-wrap iphorm-clearfix iphorm-labels-above iphorm-element-required\" >\n    <div class=\"iphorm-element-spacer iphorm-element-spacer-captcha g-recaptcha-response-element-spacer\">\n        <label class=\"g-recaptcha-response-outer-label\" >Type the words<span class=\"iphorm-required\">(required)<\/span><\/label>        <div class=\"iphorm-input-wrap iphorm-input-wrap-recaptcha g-recaptcha-response-input-wrap\" >\n                            <div id=\"iphorm_5_84_6acc3aa337628\" class=\"iphorm-recaptcha\" data-unique-id=\"iphorm_5_84_6acc3aa337628\" data-config=\"{&quot;sitekey&quot;:&quot;6LedJT8UAAAAAF98QMjpclkDUi0x8zoTC2M7u2VB&quot;,&quot;theme&quot;:&quot;light&quot;,&quot;type&quot;:&quot;image&quot;,&quot;size&quot;:&quot;normal&quot;}\"><\/div>\n                <noscript>\n                  <div style=\"width: 302px; height: 352px;\">\n                    <div style=\"width: 302px; height: 352px; position: relative;\">\n                      <div style=\"width: 302px; height: 352px; position: absolute;\">\n                        <iframe src=\"https:\/\/www.google.com\/recaptcha\/api\/fallback?k=6LedJT8UAAAAAF98QMjpclkDUi0x8zoTC2M7u2VB\"\n                                frameborder=\"0\" scrolling=\"no\"\n                                style=\"width: 302px; height:352px; border-style: none;\">\n                        <\/iframe>\n                      <\/div>\n                      <div style=\"width: 250px; height: 80px; position: absolute; border-style: none;\n                                  bottom: 21px; left: 25px; margin: 0px; padding: 0px; right: 25px;\">\n                        <textarea name=\"g-recaptcha-response\" class=\"g-recaptcha-response\"\n                                  style=\"width: 250px; height: 80px; border: 1px solid #c1c1c1;\n                                         margin: 0px; padding: 0px; resize: none;\"><\/textarea>\n                      <\/div>\n                    <\/div>\n                  <\/div>\n                <\/noscript>\n                                <\/div>\n        <div class=\"iphorm-errors-wrap iphorm-hidden\" >\r\n    <\/div>    <\/div>\n<\/div><div class=\"iphorm-hidden\">\n    <label>This field should be left blank<input type=\"text\" name=\"iphorm_5_0\" \/><\/label>\n<\/div>                <div class=\"iphorm-submit-wrap iphorm-submit-wrap-5 iphorm-clearfix\" >\n                    <div class=\"iphorm-submit-input-wrap iphorm-submit-input-wrap-5\" >\n                        <button class=\"iphorm-submit-element\" type=\"submit\" name=\"iphorm_submit\" ><span ><em >ORDER<\/em><\/span><\/button>\n                    <\/div>\n                    <div class=\"iphorm-loading-wrap\"><span class=\"iphorm-loading\">Please wait...<\/span><\/div>\n                <\/div>\n            <\/div>\n                                                                        <div class=\"iphorm-success-message iphorm-hidden\" ><\/div>\n                                    <\/div>\n            <\/form>\n    <script type=\"text\/javascript\">\n    jQuery('#iphorm-outer-6acc3aa337628 script').remove();\n    <\/script>\n<\/div>\t<\/div>\r\n<\/div>\r\n<script type=\"text\/javascript\">\r\n\tjQuery(document).ready(function($){\r\n\t\tvar actyveClass = $('.form-select input[name=horoscop]:checked').val();\r\n\t\t\/\/$('.form-'+actyveClass).show();\r\n\t\t$('.form-select').on('change', function() {\r\n\t\t\tactyveClass = $('.form-select input[name=horoscop]:checked').val();\r\n\t\t\t$('.hidden-form').hide();\r\n\t\t\t$('.form-'+actyveClass).show();\r\n\t\t});\r\n\r\n\t\t$('.form-select li span').on('click', function() {\r\n\t\t\t\t$(this).closest('li').find('input').trigger('click');\r\n\t\t});\t\r\n\t\t$('.form-preloader').hide();\r\n\t\t$('.form-switch').show();\t\r\n\t});\r\n\r\n<\/script>\n<div class=\"clearboth\"><\/div><\/div> \n\t<\/div><\/div><div class=\"clearboth\"><\/div><\/div><style type=\"text\/css\">\n                   #mk-custom-box-281 {\n                        min-height:100px;\n                        padding:30px 50px;\n                        \n                        background-attachment:scroll;\n                        background-repeat:repeat;\n                        background-color:#ffffff;\n                        background-position:left top;\n                        margin-bottom:10px;\n                        border:1px solid #ededed;\n\n                  }\n                 #mk-custom-box-281 .mk-fancy-title.pattern-style span{\n                        background-color: #ffffff !important;\n                    }\n                 <\/style>\n\t<\/div><\/div>\n","protected":false},"excerpt":{"rendered":"Personal astrologer\u2019s consultations Please carefully familiarize yourself with the rules of ordering a horoscope: 1. We provide consultations of the astrologer in an oral and a written form. 2. Consultations [...]","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":[],"_links":{"self":[{"href":"http:\/\/www.e-astrology.eu\/en\/wp-json\/wp\/v2\/pages\/40"}],"collection":[{"href":"http:\/\/www.e-astrology.eu\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"http:\/\/www.e-astrology.eu\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"http:\/\/www.e-astrology.eu\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/www.e-astrology.eu\/en\/wp-json\/wp\/v2\/comments?post=40"}],"version-history":[{"count":11,"href":"http:\/\/www.e-astrology.eu\/en\/wp-json\/wp\/v2\/pages\/40\/revisions"}],"predecessor-version":[{"id":389,"href":"http:\/\/www.e-astrology.eu\/en\/wp-json\/wp\/v2\/pages\/40\/revisions\/389"}],"wp:attachment":[{"href":"http:\/\/www.e-astrology.eu\/en\/wp-json\/wp\/v2\/media?parent=40"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}