{"id":17,"date":"2021-01-19T08:01:27","date_gmt":"2021-01-19T08:01:27","guid":{"rendered":"https:\/\/homenursing.pk\/pwd\/home\/"},"modified":"2021-08-31T12:35:09","modified_gmt":"2021-08-31T12:35:09","slug":"home","status":"publish","type":"page","link":"https:\/\/homenursing.pk\/pwd\/","title":{"rendered":"Home"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"17\" class=\"elementor elementor-17\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-0123579 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"0123579\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-84a1951\" data-id=\"84a1951\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-cd47b80 elementor-widget elementor-widget-heading\" data-id=\"cd47b80\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h6 class=\"elementor-heading-title elementor-size-default\">CREATE NEW INVOICE<\/h6>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b6b9f74 elementor-widget elementor-widget-text-editor\" data-id=\"b6b9f74\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class='fluentform ff-default fluentform_wrapper_3 ffs_bootstrap_wrap'><form data-form_id=\"3\" id=\"fluentform_3\" class=\"frm-fluent-form fluent_form_3 ff-el-form-top ff_form_instance_3_1 ff-form-loading ff-form-has-steps ff_calc_form ff_calc_form ff_calc_form ff_calc_form ff_calc_form ff_calc_form ff_calc_form ff_calc_form ff_calc_form ff_calc_form ff_calc_form ff_calc_form ff_calc_form ff_calc_form ff_calc_form ff_calc_form ff_calc_form ff_calc_form ff_calc_form ff_calc_form ff_calc_form ff_calc_form ffs_bootstrap\" data-form_instance=\"ff_form_instance_3_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Home Nursing<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='17' \/><input type=\"hidden\" id=\"_fluentform_3_fluentformnonce\" name=\"_fluentform_3_fluentformnonce\" value=\"3d4d25dbac\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/pwd\/wp-json\/wp\/v2\/pages\/17\" \/><div class='ff-step-container' data-name=\"step_start-3_3\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"no\" data-enable_step_page_resume=\"no\" data-animation_type=\"slide\" ><div class='ff-step-header'><div class='ff-el-progress-status'><\/div>\n            <div class='ff-el-progress'>\n                <div class='ff-el-progress-bar'><span><\/span><\/div>\n            <\/div>\n            <ul style='display: none' class='ff-el-progress-title'>\n                <li><\/li><li><\/li>\n            <\/ul><\/div><span class='ff_step_start'><\/span><div class='ff-step-body'><div class=\"fluentform-step active\" data-name=\"step_start-3_3\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"no\" data-enable_step_page_resume=\"no\" data-animation_type=\"slide\" ><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_datetime_2' id='label_ff_3_datetime_2' aria-label=\"Last Visit\">Last Visit<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Last Visit Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_2\" value=\"\" id=\"ff_3_datetime_2\" class=\"ff-el-form-control ff-el-datepicker lastv\" placeholder=\"No previous visit found\" data-name=\"datetime_2\"  aria-invalid='false' aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_datetime_4' id='label_ff_3_datetime_4' aria-label=\"Previous Time\">Previous Time<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Previous Time Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='h:i K' type=\"text\" name=\"datetime_4\" value=\"\" id=\"ff_3_datetime_4\" class=\"ff-el-form-control ff-el-datepicker ptime\" placeholder=\"Previous Time\" data-name=\"datetime_4\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_datetime' id='label_ff_3_datetime' aria-label=\"Date\">Date<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" value=\"17\/04\/2026\" id=\"ff_3_datetime\" class=\"ff-el-form-control ff-el-datepicker cdate\" placeholder=\"Select Date\" data-name=\"datetime\"  aria-invalid='false' aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_datetime_3' id='label_ff_3_datetime_3' aria-label=\"Current Time\">Current Time<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Current Time Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='h:i K' type=\"text\" name=\"datetime_3\" value=\"12:53 K\" id=\"ff_3_datetime_3\" class=\"ff-el-form-control ff-el-datepicker ctime\" placeholder=\"Current Time\" data-name=\"datetime_3\"  aria-invalid='false' aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_numeric-field_45' id='label_ff_3_numeric-field_45' aria-label=\"Refund\">Refund<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_45\" id=\"ff_3_numeric-field_45\" class=\"ff-el-form-control\" placeholder=\"Refund Amount\" data-name=\"numeric-field_45\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dropdown_12' id='label_ff_3_dropdown_12' aria-label=\"Receipt Type\">Receipt Type<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_12\" id=\"ff_3_dropdown_12\" class=\"ff-el-form-control rtype\" data-name=\"dropdown_12\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"false\" aria-labelledby=\"label_ff_3_dropdown_12\"><option value=\"\">-Receipt Type-<\/option><option value=\"Home Nursing\"  selected>Home Nursing<\/option><option value=\"Physiotherapy\"  >Physiotherapy<\/option><\/select><\/div><\/div><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_1' id='label_ff_3_input_text_1' aria-label=\"Previous Invoice\">Previous Invoice<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" value=\"\" class=\"ff-el-form-control pinvoice\" placeholder=\"No Previous Invoice\" maxlength=\"5\" data-name=\"input_text_1\" id=\"ff_3_input_text_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-hide_label'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_first_name_' id='label_ff_3_names_first_name_' >Patient Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" value=\"\" id=\"ff_3_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"Patient Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div data-type=\"name-element\" data-name=\"names_1\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-hide_label'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_1_first_name_' id='label_ff_3_names_1_first_name_' >Father\/Husband Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_1[first_name]\" value=\"\" id=\"ff_3_names_1_first_name_\" class=\"ff-el-form-control\" placeholder=\"Father\/Husband Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_datetime_1' id='label_ff_3_datetime_1' aria-label=\"Date Of Birth\">Date Of Birth<\/label><div class=\"ff-el-tooltip\" data-content=\"Date of Birth\"><svg width=\"16\" height=\"16\" viewBox=\"0 0 25 25\"><path d=\"m329 393l0-46c0-2-1-4-2-6-2-2-4-3-7-3l-27 0 0-146c0-3-1-5-3-7-2-1-4-2-7-2l-91 0c-3 0-5 1-7 2-1 2-2 4-2 7l0 46c0 2 1 5 2 6 2 2 4 3 7 3l27 0 0 91-27 0c-3 0-5 1-7 3-1 2-2 4-2 6l0 46c0 3 1 5 2 7 2 1 4 2 7 2l128 0c3 0 5-1 7-2 1-2 2-4 2-7z m-36-256l0-46c0-2-1-4-3-6-2-2-4-3-7-3l-54 0c-3 0-5 1-7 3-2 2-3 4-3 6l0 46c0 3 1 5 3 7 2 1 4 2 7 2l54 0c3 0 5-1 7-2 2-2 3-4 3-7z m182 119c0 40-9 77-29 110-20 34-46 60-80 80-33 20-70 29-110 29-40 0-77-9-110-29-34-20-60-46-80-80-20-33-29-70-29-110 0-40 9-77 29-110 20-34 46-60 80-80 33-20 70-29 110-29 40 0 77 9 110 29 34 20 60 46 80 80 20 33 29 70 29 110z\" transform=\"scale(0.046875 0.046875)\"><\/path><\/svg><\/div><\/div><div class='ff-el-input--content'><input  aria-label='Date Of Birth Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_1\" value=\"\" id=\"ff_3_datetime_1\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"Date Of Birth\" data-name=\"datetime_1\"  aria-invalid='false' aria-required=true><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_email' id='label_ff_3_email' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" value=\"\" id=\"ff_3_email\" class=\"ff-el-form-control\" placeholder=\"Email Address\" data-name=\"email\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_phone' id='label_ff_3_phone' aria-label=\"Mobile\">Mobile<\/label><\/div><div class='ff-el-input--content'><input name=\"phone\" class=\"ff-el-form-control ff-el-phone\" value=\"\" type=\"tel\" placeholder=\"923215555555\" data-name=\"phone\" id=\"ff_3_phone\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dropdown_1' id='label_ff_3_dropdown_1' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_1\" id=\"ff_3_dropdown_1\" class=\"ff-el-form-control\" data-name=\"dropdown_1\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"false\" aria-labelledby=\"label_ff_3_dropdown_1\"><option value=\"\">&#8211; Select City-<\/option><option value=\"Lahore\"  >Lahore<\/option><option value=\"Rawalpindi\"  selected>Rawalpindi<\/option><option value=\"Islamabad\"  >Islamabad<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown' id='label_ff_3_dropdown' aria-label=\"Area\/Address\">Area\/Address<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown\" id=\"ff_3_dropdown\" class=\"ff-el-form-control\" data-name=\"dropdown\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_dropdown\"><option value=\"\">&#8211; Select Area-<\/option><option value=\"Airport Housing Society\"  >Airport Housing Society<\/option><option value=\"Aqsa Town\"  >Aqsa Town<\/option><option value=\"Bahria Town\"  >Bahria Town<\/option><option value=\"CBR Town\"  >CBR Town<\/option><option value=\"Chaklala\"  >Chaklala<\/option><option value=\"Chandni Chowk\"  >Chandni Chowk<\/option><option value=\"DHA\"  >DHA<\/option><option value=\"Doctors Town\"  >Doctors Town<\/option><option value=\"Fazaia Colony\"  >Fazaia Colony<\/option><option value=\"Fazal Town\"  >Fazal Town<\/option><option value=\"Ghauri Town\"  >Ghauri Town<\/option><option value=\"Gulberg\"  >Gulberg<\/option><option value=\"Gulraiz\"  >Gulraiz<\/option><option value=\"Gulzar e Quaid\"  >Gulzar e Quaid<\/option><option value=\"Jinnah Gardens\"  >Jinnah Gardens<\/option><option value=\"Judicial Colony\"  >Judicial Colony<\/option><option value=\"Khanna Pul\"  >Khanna Pul<\/option><option value=\"Korang Town\"  >Korang Town<\/option><option value=\"Lohi Bher\"  >Lohi Bher<\/option><option value=\"Media Town\"  >Media Town<\/option><option value=\"Model Town\"  >Model Town<\/option><option value=\"Naval Anchorage\"  >Naval Anchorage<\/option><option value=\"New Lala Zar\"  >New Lala Zar<\/option><option value=\"Pakistan Town\"  >Pakistan Town<\/option><option value=\"Police Foundation\"  >Police Foundation<\/option><option value=\"PWD\"  >PWD<\/option><option value=\"Raja Bazar\"  >Raja Bazar<\/option><option value=\"River Gardens\"  >River Gardens<\/option><option value=\"Scheme 3\"  >Scheme 3<\/option><option value=\"Shaheen Town\"  >Shaheen Town<\/option><option value=\"Soan Gardens\"  >Soan Gardens<\/option><option value=\"Other\"  >Other<\/option><\/select><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text' id='label_ff_3_input_text' aria-label=\"Other Area\">Other Area<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" value=\"\" class=\"ff-el-form-control\" placeholder=\"Other Area\" data-name=\"input_text\" id=\"ff_3_input_text\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_2' id='label_ff_3_input_text_2' aria-label=\"Doctor\">Doctor<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" value=\"\" class=\"ff-el-form-control\" placeholder=\"Doctor Name\" data-name=\"input_text_2\" id=\"ff_3_input_text_2\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_14' id='label_ff_3_dropdown_14' aria-label=\"Doctor\">Doctor<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_14\" id=\"ff_3_dropdown_14\" class=\"ff-el-form-control\" data-name=\"dropdown_14\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_dropdown_14\"><option value=\"\">&#8211; Select Doctor-<\/option><option value=\"Dr Saman Tauseef\"  selected>Dr Saman Tauseef<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dropdown_3' id='label_ff_3_dropdown_3' aria-label=\"Checkup Type\">Checkup Type<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_3\" id=\"ff_3_dropdown_3\" class=\"ff-el-form-control\" data-name=\"dropdown_3\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"false\" aria-labelledby=\"label_ff_3_dropdown_3\"><option value=\"\">&#8211; Select Checkup Type-<\/option><option value=\"Visit Charges\"  selected>Treatment\/Procedures<\/option><\/select><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_13' id='label_ff_3_dropdown_13' aria-label=\"Physiotherapist\">Physiotherapist<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_13\" id=\"ff_3_dropdown_13\" class=\"ff-el-form-control\" data-name=\"dropdown_13\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_dropdown_13\"><option value=\"\">&#8211; Select Physiotherapist-<\/option><option value=\"Muhammad Siraj\"  selected>Muhammad Siraj<\/option><option value=\"Ayesha Ahmad\"  >Ayesha Ahmad<\/option><\/select><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_46' id='label_ff_3_numeric-field_46' aria-label=\"Visit Charges\">Visit Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_46\" value=\"500\" id=\"ff_3_numeric-field_46\" class=\"ff-el-form-control\" placeholder=\"Visit Charges\" data-name=\"numeric-field_46\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_5' id='label_ff_3_dropdown_5' aria-label=\"Nurse\">Nurse<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_5\" id=\"ff_3_dropdown_5\" class=\"ff-el-form-control\" data-name=\"dropdown_5\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_dropdown_5\"><option value=\"\">&#8211; Select Nurse-<\/option><option value=\"Saddam\"  >Saddam<\/option><option value=\"Atif\"  >Atif<\/option><option value=\"Masood\"  >Masood<\/option><option value=\"Saleem\"  selected>Saleem<\/option><option value=\"Hajra\"  >Hajra<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dropdown_4' id='label_ff_3_dropdown_4' aria-label=\"Payment Method\">Payment Method<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_4\" id=\"ff_3_dropdown_4\" class=\"ff-el-form-control\" data-name=\"dropdown_4\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"false\" aria-labelledby=\"label_ff_3_dropdown_4\"><option value=\"\">&#8211; Payment Method &#8211;<\/option><option value=\"Cash\"  selected>Cash<\/option><option value=\"Internet Banking\"  >Internet Banking<\/option><option value=\"JazzCash\"  >JazzCash<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dropdown_6' id='label_ff_3_dropdown_6' aria-label=\"Other Procedures\">Other Procedures<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_6\" id=\"ff_3_dropdown_6\" class=\"ff-el-form-control\" data-name=\"dropdown_6\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"false\" aria-labelledby=\"label_ff_3_dropdown_6\"><option value=\"\">&#8211; Procedures &#8211;<\/option><option value=\"Yes\"  selected>Yes<\/option><option value=\"No\"  >No<\/option><\/select><\/div><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div class=\" fluentform-step\" data-name=\"form_step-3_1\" ><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"IV Canula insertion (without supplies)\">IV Canula insertion (without supplies)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_6a6ca92638ad6b3a728cedd2bdf05b27'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"IV Canula insertion (without supplies)\" data-calc_value=\"300\"  id='checkbox_6a6ca92638ad6b3a728cedd2bdf05b27' aria-label='IV Canula insertion (without supplies)' aria-invalid='false' aria-required=false> <span>IV Canula insertion (without supplies)<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"IM Injection (Fee)\">IM Injection (Fee)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_1a42e829c0d701595926ec09e6c1588f'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"IM Injection (Fee)\" data-calc_value=\"150\"  id='checkbox_1_1a42e829c0d701595926ec09e6c1588f' aria-label='IM Injection (Fee)' aria-invalid='false' aria-required=false> <span>IM Injection (Fee)<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"IV Injection (Fee)\">IV Injection (Fee)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4_5f54dd0aed8a6459cbca651cb4efe380'><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"IV Injection (Fee)\" data-calc_value=\"200\"  id='checkbox_4_5f54dd0aed8a6459cbca651cb4efe380' aria-label='IV Injection (Fee)' aria-invalid='false' aria-required=false> <span>IV Injection (Fee)<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_8\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Suppository Insertion\">Suppository Insertion<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3_4bef22bcb1cb7d62dbb25eea26e81bc4'><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Suppository Insertion\" data-calc_value=\"150\"  id='checkbox_3_4bef22bcb1cb7d62dbb25eea26e81bc4' aria-label='Suppository Insertion' aria-invalid='false' aria-required=false> <span>Suppository Insertion<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Rectal Enema\">Rectal Enema<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_70a59a03f729bdf90264e7a6ca180489'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Rectal Enema\" data-calc_value=\"200\"  id='checkbox_2_70a59a03f729bdf90264e7a6ca180489' aria-label='Rectal Enema' aria-invalid='false' aria-required=false> <span>Rectal Enema<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Retain Charges (Hourly)\">Retain Charges (Hourly)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_5_721aad67e041b6edeb2815542858cbb4'><input  type=\"checkbox\" name=\"checkbox_5[]\" data-name=\"checkbox_5\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Retain Charges (Hourly)\" data-calc_value=\"500\"  id='checkbox_5_721aad67e041b6edeb2815542858cbb4' aria-label='Retain Charges (Hourly)' aria-invalid='false' aria-required=false> <span>Retain Charges (Hourly)<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_9\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"BSR\">BSR<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_6_e22319d12f826203375c3819b594e149'><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"BSR\" data-calc_value=\"100\"  id='checkbox_6_e22319d12f826203375c3819b594e149' aria-label='BSR' aria-invalid='false' aria-required=false> <span>BSR<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Steri Strip\">Steri Strip<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_7_8563d3640c89872cc4b9c28e8feb4742'><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Steri Strip\" data-calc_value=\"500\"  id='checkbox_7_8563d3640c89872cc4b9c28e8feb4742' aria-label='Steri Strip' aria-invalid='false' aria-required=false> <span>Steri Strip<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Electrocautery\">Electrocautery<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_10_72d9fc5c33d1de017721f0e21884e1ca'><input  type=\"checkbox\" name=\"checkbox_10[]\" data-name=\"checkbox_10\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Electrocautery\" data-calc_value=\"2000\"  id='checkbox_10_72d9fc5c33d1de017721f0e21884e1ca' aria-label='Electrocautery' aria-invalid='false' aria-required=false> <span>Electrocautery<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_10\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Minor Dressing By Nurse\">Minor Dressing By Nurse<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_8_96c23ce18647ea160411fe269a55f61d'><input  type=\"checkbox\" name=\"checkbox_8[]\" data-name=\"checkbox_8\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Minor Dressing (Nurse)\" data-calc_value=\"200\"  id='checkbox_8_96c23ce18647ea160411fe269a55f61d' aria-label='Minor Dressing (Nurse)' aria-invalid='false' aria-required=false> <span>Minor Dressing (Nurse)<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Foley Catheter Insertion (Without Supplies)\">Foley Catheter Insertion (Without Supplies)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_14_89a35d5e6305fb30aa74c2a056df917b'><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Foley Catheter Insertion (Without Supplies)\" data-calc_value=\"1000\"  id='checkbox_14_89a35d5e6305fb30aa74c2a056df917b' aria-label='Foley Catheter Insertion (Without Supplies)' aria-invalid='false' aria-required=false> <span>Foley Catheter Insertion (Without Supplies)<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Physiotherapy Sessions\">Physiotherapy Sessions<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='checkbox_16_760b778effbee984938f670a8e758eb0'><input  type=\"checkbox\" name=\"checkbox_16[]\" data-name=\"checkbox_16\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" checked=\"1\" value=\"Physiotherapy Sessions\"  id='checkbox_16_760b778effbee984938f670a8e758eb0' aria-label='Physiotherapy Sessions' aria-invalid='false' aria-required=false> <span>Physiotherapy Sessions<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Major Dressing By Nurse\">Major Dressing By Nurse<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_9_d8060af1951d0715e1189d05a0ae4d34'><input  type=\"checkbox\" name=\"checkbox_9[]\" data-name=\"checkbox_9\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Major Dressing (Nurse)\" data-calc_value=\"300\"  id='checkbox_9_d8060af1951d0715e1189d05a0ae4d34' aria-label='Major Dressing (Nurse)' aria-invalid='false' aria-required=false> <span>Major Dressing (Nurse)<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Nebulization (Without Medicine)\">Nebulization (Without Medicine)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_15_82db81458b873b9127af0301b6e1a139'><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Nebulization (Without Medicine)\" data-calc_value=\"300\"  id='checkbox_15_82db81458b873b9127af0301b6e1a139' aria-label='Nebulization (Without Medicine)' aria-invalid='false' aria-required=false> <span>Nebulization (Without Medicine)<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Major Dressing By Doctor\">Major Dressing By Doctor<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_11_ea8bcece03685b965d8fe5895a71aa74'><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Major Dressing (Doctor)\"  id='checkbox_11_ea8bcece03685b965d8fe5895a71aa74' aria-label='Major Dressing (Doctor)' aria-invalid='false' aria-required=false> <span>Major Dressing (Doctor)<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions  ff_list_buttons'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Stitches\">Stitches<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_12_c5909c16b38efbe6c6dd1199943d193e'><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Stitches\"  id='checkbox_12_c5909c16b38efbe6c6dd1199943d193e' aria-label='Stitches' aria-invalid='false' aria-required=false> <span>Stitches<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_datetime_5' id='label_ff_3_datetime_5' aria-label=\"Session Dates\">Session Dates<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Session Dates Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_5\" id=\"ff_3_datetime_5\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"Session Dates\" data-name=\"datetime_5\"  aria-invalid='false' aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_11\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_2' id='label_ff_3_numeric-field_2' aria-label=\"IV Canula\">IV Canula<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_2\" id=\"ff_3_numeric-field_2\" class=\"ff-el-form-control\" placeholder=\"Number of IV Canula\" data-name=\"numeric-field_2\" inputmode=\"numeric\" step=\"any\" min=\"1\" aria-valuemin=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_3' id='label_ff_3_numeric-field_3' aria-label=\"Number of IM Injections\">Number of IM Injections<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_3\" id=\"ff_3_numeric-field_3\" class=\"ff-el-form-control\" placeholder=\"Number of IM Injections\" data-name=\"numeric-field_3\" inputmode=\"numeric\" step=\"any\" min=\"1\" aria-valuemin=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_7' id='label_ff_3_numeric-field_7' aria-label=\"Number of IV Injections\">Number of IV Injections<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_7\" id=\"ff_3_numeric-field_7\" class=\"ff-el-form-control\" placeholder=\"Number of IV Injections\" data-name=\"numeric-field_7\" inputmode=\"numeric\" step=\"any\" min=\"1\" aria-valuemin=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_6' id='label_ff_3_numeric-field_6' aria-label=\"Suppository Insertion\">Suppository Insertion<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_6\" id=\"ff_3_numeric-field_6\" class=\"ff-el-form-control\" placeholder=\"Number of Supp Insertion\" data-name=\"numeric-field_6\" inputmode=\"numeric\" step=\"any\" min=\"1\" aria-valuemin=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_5' id='label_ff_3_numeric-field_5' aria-label=\"Rectal Enema\">Rectal Enema<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_5\" id=\"ff_3_numeric-field_5\" class=\"ff-el-form-control\" placeholder=\"Number of Rectal Enema\" data-name=\"numeric-field_5\" inputmode=\"numeric\" step=\"any\" min=\"1\" aria-valuemin=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_4' id='label_ff_3_numeric-field_4' aria-label=\"Retain Hours\">Retain Hours<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_4\" id=\"ff_3_numeric-field_4\" class=\"ff-el-form-control\" placeholder=\"Number of Retain Hours\" data-name=\"numeric-field_4\" inputmode=\"numeric\" step=\"any\" min=\"0.5\" aria-valuemin=\"0.5\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_47' id='label_ff_3_numeric-field_47' aria-label=\"BSR\">BSR<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_47\" id=\"ff_3_numeric-field_47\" class=\"ff-el-form-control\" placeholder=\"Number of BSR\" data-name=\"numeric-field_47\" inputmode=\"numeric\" step=\"any\" min=\"1\" aria-valuemin=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_50' id='label_ff_3_numeric-field_50' aria-label=\"Steri Strip\">Steri Strip<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_50\" id=\"ff_3_numeric-field_50\" class=\"ff-el-form-control\" placeholder=\"Number of Steri Strip\" data-name=\"numeric-field_50\" inputmode=\"numeric\" step=\"any\" min=\"1\" aria-valuemin=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_54' id='label_ff_3_numeric-field_54' aria-label=\"Minor Dressing By Nurse\">Minor Dressing By Nurse<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_54\" id=\"ff_3_numeric-field_54\" class=\"ff-el-form-control\" placeholder=\"Minor Dressings By Nurse\" data-name=\"numeric-field_54\" inputmode=\"numeric\" step=\"any\" min=\"1\" aria-valuemin=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_57' id='label_ff_3_numeric-field_57' aria-label=\"Major Dressing By Nurse\">Major Dressing By Nurse<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_57\" id=\"ff_3_numeric-field_57\" class=\"ff-el-form-control\" placeholder=\"Major Dressings By Nurse\" data-name=\"numeric-field_57\" inputmode=\"numeric\" step=\"any\" min=\"1\" aria-valuemin=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_63' id='label_ff_3_numeric-field_63' aria-label=\"Major Dressing By Doctor\">Major Dressing By Doctor<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_63\" id=\"ff_3_numeric-field_63\" class=\"ff-el-form-control\" placeholder=\"Major Dressings By Doctor\" data-name=\"numeric-field_63\" inputmode=\"numeric\" step=\"any\" min=\"1\" aria-valuemin=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_66' id='label_ff_3_numeric-field_66' aria-label=\"Number of Stitches\">Number of Stitches<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_66\" id=\"ff_3_numeric-field_66\" class=\"ff-el-form-control\" placeholder=\"Number of Stitches\" data-name=\"numeric-field_66\" inputmode=\"numeric\" step=\"any\" min=\"1\" aria-valuemin=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_60' id='label_ff_3_numeric-field_60' aria-label=\"Electrocautery\">Electrocautery<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_60\" id=\"ff_3_numeric-field_60\" class=\"ff-el-form-control\" placeholder=\"Number of Electrocautery\" data-name=\"numeric-field_60\" inputmode=\"numeric\" step=\"any\" min=\"1\" aria-valuemin=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_71' id='label_ff_3_numeric-field_71' aria-label=\"Number of FCI\">Number of FCI<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_71\" id=\"ff_3_numeric-field_71\" class=\"ff-el-form-control\" placeholder=\"Number of FCI\" data-name=\"numeric-field_71\" inputmode=\"numeric\" step=\"any\" min=\"1\" aria-valuemin=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_74' id='label_ff_3_numeric-field_74' aria-label=\"Number of Nebulization (Without Medicine)\">Number of Nebulization (Without Medicine)<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_74\" id=\"ff_3_numeric-field_74\" class=\"ff-el-form-control\" placeholder=\"Number of Nebulization (Without Medicine)\" data-name=\"numeric-field_74\" inputmode=\"numeric\" step=\"any\" min=\"1\" aria-valuemin=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_77' id='label_ff_3_numeric-field_77' aria-label=\"Number of Sessions\">Number of Sessions<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_77\" id=\"ff_3_numeric-field_77\" class=\"ff-el-form-control\" placeholder=\"Number of Sessions\" data-name=\"numeric-field_77\" inputmode=\"numeric\" step=\"any\" min=\"1\" aria-valuemin=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_9' id='label_ff_3_numeric-field_9' aria-label=\"IV Canula Price\">IV Canula Price<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_9\" value=\"500\" id=\"ff_3_numeric-field_9\" class=\"ff-el-form-control\" data-name=\"numeric-field_9\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_10' id='label_ff_3_numeric-field_10' aria-label=\"IM Injection Price\">IM Injection Price<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_10\" value=\"500\" id=\"ff_3_numeric-field_10\" class=\"ff-el-form-control\" data-name=\"numeric-field_10\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_12' id='label_ff_3_numeric-field_12' aria-label=\"IV Injection Price\">IV Injection Price<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_12\" value=\"500\" id=\"ff_3_numeric-field_12\" class=\"ff-el-form-control\" data-name=\"numeric-field_12\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_14' id='label_ff_3_numeric-field_14' aria-label=\"Suppository Insertion Price\">Suppository Insertion Price<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_14\" value=\"500\" id=\"ff_3_numeric-field_14\" class=\"ff-el-form-control\" data-name=\"numeric-field_14\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_16' id='label_ff_3_numeric-field_16' aria-label=\"Rectal Enema Price\">Rectal Enema Price<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_16\" value=\"500\" id=\"ff_3_numeric-field_16\" class=\"ff-el-form-control\" data-name=\"numeric-field_16\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_18' id='label_ff_3_numeric-field_18' aria-label=\"Retain Charges\">Retain Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_18\" value=\"500\" id=\"ff_3_numeric-field_18\" class=\"ff-el-form-control\" data-name=\"numeric-field_18\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_48' id='label_ff_3_numeric-field_48' aria-label=\"BSR Charges\">BSR Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_48\" value=\"500\" id=\"ff_3_numeric-field_48\" class=\"ff-el-form-control\" data-name=\"numeric-field_48\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_51' id='label_ff_3_numeric-field_51' aria-label=\"Steri Strip Charges\">Steri Strip Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_51\" value=\"500\" id=\"ff_3_numeric-field_51\" class=\"ff-el-form-control\" data-name=\"numeric-field_51\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_55' id='label_ff_3_numeric-field_55' aria-label=\"Minor Dressing (Nurse) Charges\">Minor Dressing (Nurse) Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_55\" value=\"500\" id=\"ff_3_numeric-field_55\" class=\"ff-el-form-control\" data-name=\"numeric-field_55\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_58' id='label_ff_3_numeric-field_58' aria-label=\"Major Dressing (Nurse) Charges\">Major Dressing (Nurse) Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_58\" value=\"500\" id=\"ff_3_numeric-field_58\" class=\"ff-el-form-control\" data-name=\"numeric-field_58\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_64' id='label_ff_3_numeric-field_64' aria-label=\"Major Dressing (Doctor) Charges\">Major Dressing (Doctor) Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_64\" value=\"1500\" id=\"ff_3_numeric-field_64\" class=\"ff-el-form-control\" data-name=\"numeric-field_64\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_67' id='label_ff_3_numeric-field_67' aria-label=\"Charges per stitch\">Charges per stitch<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_67\" value=\"200\" id=\"ff_3_numeric-field_67\" class=\"ff-el-form-control\" data-name=\"numeric-field_67\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_61' id='label_ff_3_numeric-field_61' aria-label=\"Electrocautery Charges\">Electrocautery Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_61\" value=\"500\" id=\"ff_3_numeric-field_61\" class=\"ff-el-form-control\" data-name=\"numeric-field_61\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_72' id='label_ff_3_numeric-field_72' aria-label=\"Foley Catheter Insertion (Without Supplies)\">Foley Catheter Insertion (Without Supplies)<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_72\" value=\"500\" id=\"ff_3_numeric-field_72\" class=\"ff-el-form-control\" data-name=\"numeric-field_72\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_75' id='label_ff_3_numeric-field_75' aria-label=\"Nebulization (Without Medicine)\">Nebulization (Without Medicine)<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_75\" value=\"500\" id=\"ff_3_numeric-field_75\" class=\"ff-el-form-control\" data-name=\"numeric-field_75\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_78' id='label_ff_3_numeric-field_78' aria-label=\"Fee per session\">Fee per session<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_78\" value=\"500\" id=\"ff_3_numeric-field_78\" class=\"ff-el-form-control\" data-name=\"numeric-field_78\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_8' id='label_ff_3_numeric-field_8' aria-label=\"IV Canula Amount\">IV Canula Amount<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"numeric-field_8\" id=\"ff_3_numeric-field_8\" class=\"ff-el-form-control  ff_has_formula\" data-name=\"numeric-field_8\" data-calculation_formula=\"{input.numeric-field_2}*{input.numeric-field_9}\" readonly=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_11' id='label_ff_3_numeric-field_11' aria-label=\"IM Injection Amount\">IM Injection Amount<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"numeric-field_11\" id=\"ff_3_numeric-field_11\" class=\"ff-el-form-control  ff_has_formula\" data-name=\"numeric-field_11\" data-calculation_formula=\"{input.numeric-field_3}*{input.numeric-field_10}\" readonly=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_13' id='label_ff_3_numeric-field_13' aria-label=\"IV Injection Amount\">IV Injection Amount<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"numeric-field_13\" id=\"ff_3_numeric-field_13\" class=\"ff-el-form-control  ff_has_formula\" data-name=\"numeric-field_13\" data-calculation_formula=\"{input.numeric-field_7}*{input.numeric-field_12}\" readonly=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_15' id='label_ff_3_numeric-field_15' aria-label=\"Suppository Insertion Amount\">Suppository Insertion Amount<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"numeric-field_15\" id=\"ff_3_numeric-field_15\" class=\"ff-el-form-control  ff_has_formula\" data-name=\"numeric-field_15\" data-calculation_formula=\"{input.numeric-field_6}*{input.numeric-field_14}\" readonly=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_17' id='label_ff_3_numeric-field_17' aria-label=\"Rectal Enema Amount\">Rectal Enema Amount<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"numeric-field_17\" id=\"ff_3_numeric-field_17\" class=\"ff-el-form-control  ff_has_formula\" data-name=\"numeric-field_17\" data-calculation_formula=\"{input.numeric-field_5}*{input.numeric-field_16}\" readonly=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_19' id='label_ff_3_numeric-field_19' aria-label=\"Retain Charges\">Retain Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"numeric-field_19\" id=\"ff_3_numeric-field_19\" class=\"ff-el-form-control  ff_has_formula\" data-name=\"numeric-field_19\" data-calculation_formula=\"{input.numeric-field_4}*{input.numeric-field_18}\" readonly=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_49' id='label_ff_3_numeric-field_49' aria-label=\"BSR Charges\">BSR Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"numeric-field_49\" id=\"ff_3_numeric-field_49\" class=\"ff-el-form-control  ff_has_formula\" data-name=\"numeric-field_49\" data-calculation_formula=\"{input.numeric-field_47}*{input.numeric-field_48}\" readonly=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_52' id='label_ff_3_numeric-field_52' aria-label=\"Steri Strip Charges\">Steri Strip Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"numeric-field_52\" id=\"ff_3_numeric-field_52\" class=\"ff-el-form-control  ff_has_formula\" data-name=\"numeric-field_52\" data-calculation_formula=\"{input.numeric-field_50}*{input.numeric-field_51}\" readonly=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_56' id='label_ff_3_numeric-field_56' aria-label=\"Minor Dressing (Nurse) Charges\">Minor Dressing (Nurse) Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"numeric-field_56\" id=\"ff_3_numeric-field_56\" class=\"ff-el-form-control  ff_has_formula\" data-name=\"numeric-field_56\" data-calculation_formula=\"{input.numeric-field_54}*{input.numeric-field_55}\" readonly=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_59' id='label_ff_3_numeric-field_59' aria-label=\"Major Dressing (Nurse) Charges\">Major Dressing (Nurse) Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"numeric-field_59\" id=\"ff_3_numeric-field_59\" class=\"ff-el-form-control  ff_has_formula\" data-name=\"numeric-field_59\" data-calculation_formula=\"{input.numeric-field_57}*{input.numeric-field_58}\" readonly=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_65' id='label_ff_3_numeric-field_65' aria-label=\"Major Dressing (Doctor) Charges\">Major Dressing (Doctor) Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"numeric-field_65\" id=\"ff_3_numeric-field_65\" class=\"ff-el-form-control  ff_has_formula\" data-name=\"numeric-field_65\" data-calculation_formula=\"{input.numeric-field_63}*{input.numeric-field_64}\" readonly=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_68' id='label_ff_3_numeric-field_68' aria-label=\"Major Dressing (Doctor) Charges\">Major Dressing (Doctor) Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"numeric-field_68\" id=\"ff_3_numeric-field_68\" class=\"ff-el-form-control  ff_has_formula\" data-name=\"numeric-field_68\" data-calculation_formula=\"{input.numeric-field_66}*{input.numeric-field_67}\" readonly=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_62' id='label_ff_3_numeric-field_62' aria-label=\"Electrocautery Charges\">Electrocautery Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"numeric-field_62\" id=\"ff_3_numeric-field_62\" class=\"ff-el-form-control  ff_has_formula\" data-name=\"numeric-field_62\" data-calculation_formula=\"{input.numeric-field_60}*{input.numeric-field_61}\" readonly=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_73' id='label_ff_3_numeric-field_73' aria-label=\"FCI Charges\">FCI Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"numeric-field_73\" id=\"ff_3_numeric-field_73\" class=\"ff-el-form-control  ff_has_formula\" data-name=\"numeric-field_73\" data-calculation_formula=\"{input.numeric-field_71}*{input.numeric-field_72}\" readonly=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_76' id='label_ff_3_numeric-field_76' aria-label=\"Nebulization (Without Medicine) Charges\">Nebulization (Without Medicine) Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"numeric-field_76\" id=\"ff_3_numeric-field_76\" class=\"ff-el-form-control  ff_has_formula\" data-name=\"numeric-field_76\" data-calculation_formula=\"{input.numeric-field_74}*{input.numeric-field_75}\" readonly=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_79' id='label_ff_3_numeric-field_79' aria-label=\"Nebulization (Without Medicine) Charges\">Nebulization (Without Medicine) Charges<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"numeric-field_79\" id=\"ff_3_numeric-field_79\" class=\"ff-el-form-control  ff_has_formula\" data-name=\"numeric-field_79\" data-calculation_formula=\"{input.numeric-field_77}*{input.numeric-field_78}\" readonly=\"1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_12\"  class='ff-t-container ff-column-container ff_columns_total_1 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_1' id='label_ff_3_numeric-field_1' aria-label=\"Total\">Total<\/label><\/div><div class='ff-el-input--content'><div class=\"ff_input-group\"><div class=\"ff_input-group-prepend\"><span class=\"ff_input-group-text\">Total<\/span><\/div><input type=\"text\" name=\"numeric-field_1\" value=\"0\" id=\"ff_3_numeric-field_1\" class=\"ff-el-form-control  ff_has_formula ff_numeric\" placeholder=\"Total Amount\" data-name=\"numeric-field_1\" data-calculation_formula=\"{input.numeric-field}+{input.numeric-field_8}+{input.numeric-field_11}+{input.numeric-field_13}+{input.numeric-field_15}+{input.numeric-field_17}+{input.numeric-field_19}+{input.numeric-field_42}+{input.numeric-field_41}+{input.numeric-field_40}+{input.numeric-field_39}+{input.numeric-field_38}+{input.numeric-field_37}+{input.numeric-field_36}+{input.numeric-field_46}+{input.numeric-field_49}+{input.numeric-field_52}+{input.numeric-field_53}+{input.numeric-field_56}+{input.numeric-field_59}+{input.numeric-field_62}+{input.numeric-field_65}+{input.numeric-field_68}+{input.numeric-field_69}+{input.numeric-field_73}+{input.numeric-field_76}+{input.numeric-field_79}\" readonly=\"1\" data-formatter=\"{&quot;decimal&quot;:&quot;.&quot;,&quot;separator&quot;:&quot;,&quot;,&quot;precision&quot;:0,&quot;symbol&quot;:&quot;&quot;}\"  aria-invalid=\"false\" aria-required=false><div class=\"ff_input-group-append\"><span class=\"ff_input-group-text\">Rs<\/span><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label  ff_list_buttons'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Discount\">Discount<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_13_8137c5242ad8c672bc597c6447abd79f'><input  type=\"checkbox\" name=\"checkbox_13[]\" data-name=\"checkbox_13\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Discount\"  id='checkbox_13_8137c5242ad8c672bc597c6447abd79f' aria-label='Discount' aria-invalid='false' aria-required=false> <span>Discount<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_20' id='label_ff_3_numeric-field_20' aria-label=\"Discount\">Discount<\/label><\/div><div class='ff-el-input--content'><div class=\"ff_input-group\"><div class=\"ff_input-group-prepend\"><span class=\"ff_input-group-text\">Discount<\/span><\/div><input type=\"text\" name=\"numeric-field_20\" id=\"ff_3_numeric-field_20\" class=\"ff-el-form-control  ff_numeric\" placeholder=\"Enter Discount\" data-name=\"numeric-field_20\" inputmode=\"numeric\" step=\"any\" data-formatter=\"{&quot;decimal&quot;:&quot;.&quot;,&quot;separator&quot;:&quot;,&quot;,&quot;precision&quot;:0,&quot;symbol&quot;:&quot;&quot;}\"  aria-invalid=\"false\" aria-required=false><div class=\"ff_input-group-append\"><span class=\"ff_input-group-text\">Rs<\/span><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_21' id='label_ff_3_numeric-field_21' aria-label=\"Net Total\">Net Total<\/label><\/div><div class='ff-el-input--content'><div class=\"ff_input-group\"><div class=\"ff_input-group-prepend\"><span class=\"ff_input-group-text\">Net Total<\/span><\/div><input type=\"text\" name=\"numeric-field_21\" id=\"ff_3_numeric-field_21\" class=\"ff-el-form-control  ff_has_formula ff_numeric\" placeholder=\"Net Total\" data-name=\"numeric-field_21\" data-calculation_formula=\"{input.numeric-field_1}-{input.numeric-field_20}\" readonly=\"1\" data-formatter=\"{&quot;decimal&quot;:&quot;.&quot;,&quot;separator&quot;:&quot;,&quot;,&quot;precision&quot;:0,&quot;symbol&quot;:&quot;&quot;}\"  aria-invalid=\"false\" aria-required=false><div class=\"ff_input-group-append\"><span class=\"ff_input-group-text\">Rs<\/span><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_22' id='label_ff_3_numeric-field_22' aria-label=\"Disposables\">Disposables<\/label><\/div><div class='ff-el-input--content'><div class=\"ff_input-group\"><div class=\"ff_input-group-prepend\"><span class=\"ff_input-group-text\">Disposables<\/span><\/div><input type=\"number\" name=\"numeric-field_22\" id=\"ff_3_numeric-field_22\" class=\"ff-el-form-control\" placeholder=\"Disposables\" data-name=\"numeric-field_22\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><div class=\"ff_input-group-append\"><span class=\"ff_input-group-text\">Rs<\/span><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_23' id='label_ff_3_numeric-field_23' aria-label=\"Gross Total\">Gross Total<\/label><\/div><div class='ff-el-input--content'><div class=\"ff_input-group\"><div class=\"ff_input-group-prepend\"><span class=\"ff_input-group-text\">Gross Total<\/span><\/div><input type=\"text\" name=\"numeric-field_23\" id=\"ff_3_numeric-field_23\" class=\"ff-el-form-control  ff_has_formula ff_numeric\" placeholder=\"Gross Total\" data-name=\"numeric-field_23\" data-calculation_formula=\"{input.numeric-field_21}-{input.numeric-field_22}\" readonly=\"1\" data-formatter=\"{&quot;decimal&quot;:&quot;.&quot;,&quot;separator&quot;:&quot;,&quot;,&quot;precision&quot;:0,&quot;symbol&quot;:&quot;&quot;}\"  aria-invalid=\"false\" aria-required=false><div class=\"ff_input-group-append\"><span class=\"ff_input-group-text\">Rs<\/span><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_24' id='label_ff_3_numeric-field_24' aria-label=\"Doctor&#039;s 50%\">Doctor&#8217;s 50%<\/label><\/div><div class='ff-el-input--content'><div class=\"ff_input-group\"><div class=\"ff_input-group-prepend\"><span class=\"ff_input-group-text\">Doctor&#8217;s 50%<\/span><\/div><input type=\"text\" name=\"numeric-field_24\" id=\"ff_3_numeric-field_24\" class=\"ff-el-form-control  ff_has_formula ff_numeric\" placeholder=\"Doctor&#039;s 50%\" data-name=\"numeric-field_24\" data-calculation_formula=\"{input.numeric-field_23}*0.5\" readonly=\"1\" data-formatter=\"{&quot;decimal&quot;:&quot;.&quot;,&quot;separator&quot;:&quot;,&quot;,&quot;precision&quot;:0,&quot;symbol&quot;:&quot;&quot;}\"  aria-invalid=\"false\" aria-required=false><div class=\"ff_input-group-append\"><span class=\"ff_input-group-text\">Rs<\/span><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_26' id='label_ff_3_numeric-field_26' aria-label=\"Doctor&#039;s 65%\">Doctor&#8217;s 65%<\/label><\/div><div class='ff-el-input--content'><div class=\"ff_input-group\"><div class=\"ff_input-group-prepend\"><span class=\"ff_input-group-text\">Doctor&#8217;s 65%<\/span><\/div><input type=\"text\" name=\"numeric-field_26\" id=\"ff_3_numeric-field_26\" class=\"ff-el-form-control  ff_has_formula ff_numeric\" placeholder=\"Doctor&#039;s 65%\" data-name=\"numeric-field_26\" data-calculation_formula=\"{input.numeric-field_23}*0.65\" readonly=\"1\" data-formatter=\"{&quot;decimal&quot;:&quot;.&quot;,&quot;separator&quot;:&quot;,&quot;,&quot;precision&quot;:0,&quot;symbol&quot;:&quot;&quot;}\"  aria-invalid=\"false\" aria-required=false><div class=\"ff_input-group-append\"><span class=\"ff_input-group-text\">Rs<\/span><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_25' id='label_ff_3_numeric-field_25' aria-label=\"Doctor&#039;s 70%\">Doctor&#8217;s 70%<\/label><\/div><div class='ff-el-input--content'><div class=\"ff_input-group\"><div class=\"ff_input-group-prepend\"><span class=\"ff_input-group-text\">Doctor&#8217;s 70%<\/span><\/div><input type=\"text\" name=\"numeric-field_25\" id=\"ff_3_numeric-field_25\" class=\"ff-el-form-control  ff_has_formula ff_numeric\" placeholder=\"Doctor&#039;s 70%\" data-name=\"numeric-field_25\" data-calculation_formula=\"{input.numeric-field_23}*0.7\" readonly=\"1\" data-formatter=\"{&quot;decimal&quot;:&quot;.&quot;,&quot;separator&quot;:&quot;,&quot;,&quot;precision&quot;:0,&quot;symbol&quot;:&quot;&quot;}\"  aria-invalid=\"false\" aria-required=false><div class=\"ff_input-group-append\"><span class=\"ff_input-group-text\">Rs<\/span><\/div><\/div><\/div><\/div><\/div><\/div><input type=\"hidden\" name=\"hidden\" data-name=\"hidden\" ><input type=\"hidden\" name=\"hidden_1\" value=\"\" data-name=\"hidden_1\" ><input type=\"hidden\" name=\"hidden_2\" data-name=\"hidden_2\" ><input type=\"hidden\" name=\"hidden_3\" data-name=\"hidden_3\" ><input type=\"hidden\" name=\"hidden_4\" data-name=\"hidden_4\" ><input type=\"hidden\" name=\"hidden_5\" data-name=\"hidden_5\" ><input type=\"hidden\" name=\"hidden_6\" data-name=\"hidden_6\" ><input type=\"hidden\" name=\"hidden_7\" data-name=\"hidden_7\" ><input type=\"hidden\" name=\"hidden_8\" data-name=\"hidden_8\" ><div class='ff-el-group ff-text-left ff_submit_btn_wrapper ff_submit_btn_wrapper_custom'><button class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style wpf_has_custom_css\" type=\"submit\" name=\"custom_submit_button-3_2\" data-name=\"custom_submit_button-3_2\"  aria-label=\"Submit\">Submit<\/button><style>form.fluent_form_3 .wpf_has_custom_css.ff-btn-submit { background-color:#409EFF;border-color:#409EFF;color:#ffffff;min-width:100%; }form.fluent_form_3 .wpf_has_custom_css.ff-btn-submit:hover { background-color:#ffffff;border-color:#409EFF;color:#409EFF;min-width:100%; } <\/style><\/div><div data-type=\"name-element\" data-name=\"names_2\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_names_2_first_name_' id='label_ff_3_names_2_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_2[first_name]\" id=\"ff_3_names_2_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your First Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_names_2_last_name_' id='label_ff_3_names_2_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_2[last_name]\" id=\"ff_3_names_2_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Last Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><div data-type=\"name-element\" data-name=\"names_3\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_names_3_first_name_' id='label_ff_3_names_3_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_3[first_name]\" id=\"ff_3_names_3_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your First Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_names_3_last_name_' id='label_ff_3_names_3_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_3[last_name]\" id=\"ff_3_names_3_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Last Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div>        <div class=\"ff-step-t-container ff-inner_submit_container ff-column-container ff_columns_total_2\">\n            <div class=\"ff-t-cell ff-t-column-1\"><div class='step-nav ff_step_nav_last'><button  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><\/div><\/div>\n            <div class=\"ff-t-cell ff-t-column-2\">\n                            <\/div>\n        <\/div>\n        <\/div><\/div><\/div>\n        <\/fieldset><\/form><div id='fluentform_3_errors' class='ff-errors-in-stack ff_form_instance_3_1 ff-form-loading_errors ff_form_instance_3_1_errors'><\/div><\/div>            <script type=\"text\/javascript\">\n                window.fluent_form_ff_form_instance_3_1 = {\"id\":\"3\",\"ajaxUrl\":\"https:\\\/\\\/homenursing.pk\\\/pwd\\\/wp-admin\\\/admin-ajax.php\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\",\"asteriskPlacement\":\"asterisk-right\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_3_1\",\"form_id_selector\":\"fluentform_3\",\"rules\":{\"datetime_2\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"datetime_4\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"datetime\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"datetime_3\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This 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is required\"}},\"email\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"},\"email\":{\"value\":true,\"message\":\"This field must contain a valid email\",\"global\":false,\"global_message\":\"This field must contain a valid email\"}},\"phone\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"},\"valid_phone_number\":{\"value\":false,\"message\":\"Phone number is not valid\",\"global\":false,\"global_message\":\"Phone number is not valid\"}},\"dropdown_1\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"dropdown\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"input_text\":{\"required\":{\"value\":true,\"message\":\"This field is 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