{"id":219,"date":"2024-07-04T10:29:16","date_gmt":"2024-07-04T08:29:16","guid":{"rendered":"https:\/\/mysolta.com\/?page_id=219"},"modified":"2024-07-16T21:35:51","modified_gmt":"2024-07-16T19:35:51","slug":"clinic","status":"publish","type":"page","link":"https:\/\/mysolta.com\/pt\/clinic\/","title":{"rendered":"Cl\u00ednica"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"219\" class=\"elementor elementor-219\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-cd9cb87 e-flex e-con-boxed e-con e-parent\" data-id=\"cd9cb87\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-746aec3 elementor-widget elementor-widget-image\" data-id=\"746aec3\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"462\" height=\"200\" src=\"https:\/\/mysolta.com\/wp-content\/uploads\/2024\/05\/logo-solta-white.png\" class=\"attachment-large size-large wp-image-32\" alt=\"\" srcset=\"https:\/\/mysolta.com\/wp-content\/uploads\/2024\/05\/logo-solta-white.png 462w, https:\/\/mysolta.com\/wp-content\/uploads\/2024\/05\/logo-solta-white-300x130.png 300w\" sizes=\"(max-width: 462px) 100vw, 462px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-1439f8f e-flex e-con-boxed e-con e-parent\" data-id=\"1439f8f\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4feadfb elementor-widget elementor-widget-shortcode\" data-id=\"4feadfb\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"trp-shortcode-switcher__wrapper\"\r\n     style=\"--bg:#ffffff;--bg-hover:#0000000d;--text:#143852;--text-hover:#1d2327;--border:1px solid #1438521a;--border-width:1px;--border-color:#1438521a;--border-radius:5px;--flag-radius:2px;--flag-size:18px;--aspect-ratio:4\/3;--font-size:14px;--transition-duration:0.2s\"\r\n     role=\"group\"\r\n     data-open-mode=\"hover\">\r\n\r\n    \r\n        <!-- ANCHOR (in-flow only; sizing\/borders; inert) -->\r\n        <div class=\"trp-language-switcher trp-ls-dropdown trp-shortcode-switcher trp-shortcode-anchor trp-open-on-hover\"\r\n             aria-hidden=\"true\"\r\n             inert\r\n             data-no-translation>\r\n                <div class=\"trp-current-language-item__wrapper\">\r\n        <a class=\"trp-language-item trp-language-item__default trp-language-item__current\" data-no-translation href=\"https:\/\/mysolta.com\/pt\/wp-json\/wp\/v2\/pages\/219#TRPLINKPROCESSED\" title=\"Portuguese\"><img decoding=\"async\" src=\"https:\/\/mysolta.com\/wp-content\/plugins\/translatepress-multilingual\/assets\/flags\/4x3\/pt_PT.svg\" class=\"trp-flag-image\" alt=\"\" role=\"presentation\" loading=\"lazy\" \/><span class=\"trp-language-item-name\">Portuguese<\/span><\/a>                    <svg class=\"trp-shortcode-arrow\" width=\"20\" height=\"20\" viewBox=\"0 0 20 21\" fill=\"none\" aria-hidden=\"true\" focusable=\"false\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\r\n                <path d=\"M5 8L10 13L15 8\" stroke=\"var(--text)\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/>\r\n            <\/svg>\r\n            <\/div>\r\n            <\/div>\r\n\r\n        <!-- OVERLAY (positioned; interactive surface) -->\r\n        <div class=\"trp-language-switcher trp-ls-dropdown trp-shortcode-switcher trp-shortcode-overlay trp-open-on-hover\"\r\n             role=\"navigation\"\r\n             aria-label=\"Seletor de idioma do site\"\r\n             data-no-translation\r\n        >\r\n                <div class=\"trp-current-language-item__wrapper\">\r\n        <div class=\"trp-language-item trp-language-item__default trp-language-item__current\" data-no-translation role=\"button\" aria-expanded=\"false\" tabindex=\"0\" aria-label=\"Alterar idioma\" aria-controls=\"trp-shortcode-dropdown-6adb2d969d52e\"><img decoding=\"async\" src=\"https:\/\/mysolta.com\/wp-content\/plugins\/translatepress-multilingual\/assets\/flags\/4x3\/pt_PT.svg\" class=\"trp-flag-image\" alt=\"\" role=\"presentation\" loading=\"lazy\" \/><span class=\"trp-language-item-name\">Portuguese<\/span><\/div>                    <svg class=\"trp-shortcode-arrow\" width=\"20\" height=\"20\" viewBox=\"0 0 20 21\" fill=\"none\" aria-hidden=\"true\" focusable=\"false\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\r\n                <path d=\"M5 8L10 13L15 8\" stroke=\"var(--text)\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/>\r\n            <\/svg>\r\n            <\/div>\r\n    \r\n            <div class=\"trp-switcher-dropdown-list\"\r\n                 id=\"trp-shortcode-dropdown-6adb2d969d52e\"\r\n                 role=\"group\"\r\n                 aria-label=\"Idiomas dispon\u00edveis\"\r\n                 hidden\r\n                 inert\r\n            >\r\n                                                            <a class=\"trp-language-item\" href=\"https:\/\/mysolta.com\/pt\/wp-json\/wp\/v2\/pages\/219#TRPLINKPROCESSED\" title=\"English\">\r\n                            <img decoding=\"async\" src=\"https:\/\/mysolta.com\/wp-content\/plugins\/translatepress-multilingual\/assets\/flags\/4x3\/en_US.svg\" class=\"trp-flag-image\" alt=\"\" role=\"presentation\" loading=\"lazy\" \/>                                                            <span class=\"trp-language-item-name\" data-no-translation>English<\/span>\r\n                                                                                <\/a>\r\n                                            <a class=\"trp-language-item\" href=\"https:\/\/mysolta.com\/pt\/wp-json\/wp\/v2\/pages\/219#TRPLINKPROCESSED\" title=\"German\">\r\n                            <img decoding=\"async\" src=\"https:\/\/mysolta.com\/wp-content\/plugins\/translatepress-multilingual\/assets\/flags\/4x3\/de_DE.svg\" class=\"trp-flag-image\" alt=\"\" role=\"presentation\" loading=\"lazy\" \/>                                                            <span class=\"trp-language-item-name\" data-no-translation>German<\/span>\r\n                                                                                <\/a>\r\n                                            <a class=\"trp-language-item\" href=\"https:\/\/mysolta.com\/pt\/wp-json\/wp\/v2\/pages\/219#TRPLINKPROCESSED\" title=\"Spanish\">\r\n                            <img decoding=\"async\" src=\"https:\/\/mysolta.com\/wp-content\/plugins\/translatepress-multilingual\/assets\/flags\/4x3\/es_ES.svg\" class=\"trp-flag-image\" alt=\"\" role=\"presentation\" loading=\"lazy\" \/>                                                            <span class=\"trp-language-item-name\" data-no-translation>Spanish<\/span>\r\n                                                                                <\/a>\r\n                                            <a class=\"trp-language-item\" href=\"https:\/\/mysolta.com\/pt\/wp-json\/wp\/v2\/pages\/219#TRPLINKPROCESSED\" title=\"Italian\">\r\n                            <img decoding=\"async\" src=\"https:\/\/mysolta.com\/wp-content\/plugins\/translatepress-multilingual\/assets\/flags\/4x3\/it_IT.svg\" class=\"trp-flag-image\" alt=\"\" role=\"presentation\" loading=\"lazy\" \/>                                                            <span class=\"trp-language-item-name\" data-no-translation>Italian<\/span>\r\n                                                                                <\/a>\r\n                                            <a class=\"trp-language-item\" href=\"https:\/\/mysolta.com\/pt\/wp-json\/wp\/v2\/pages\/219#TRPLINKPROCESSED\" title=\"French\">\r\n                            <img decoding=\"async\" src=\"https:\/\/mysolta.com\/wp-content\/plugins\/translatepress-multilingual\/assets\/flags\/4x3\/fr_FR.svg\" class=\"trp-flag-image\" alt=\"\" role=\"presentation\" loading=\"lazy\" \/>                                                            <span class=\"trp-language-item-name\" data-no-translation>French<\/span>\r\n                                                                                <\/a>\r\n                                                <\/div>\r\n        <\/div>\r\n\r\n    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#112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-btn-bg-color-hover-tertiary: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indica campos obrigat\u00f3rios<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/pt\/wp-json\/wp\/v2\/pages\/219#gf_3' data-formid='3' novalidate>\n        <div id='gf_progressbar_wrapper_3' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Passo <span class='gf_step_current_page'>1<\/span> de <span class='gf_step_page_count'>2<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_50' style='width:50%;'><span>50%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_3_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><div id=\"field_3_33\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"><label id='gfield_label_3_33' class='gfield_label gform-field-label' for='input_3_33'><span class='gform-field-label__text'>X\/Twitter<\/span><\/label><div class='ginput_container'><input name='input_33' id='input_3_33' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_3_33'>Este campo \u00e9 para efeitos de valida\u00e7\u00e3o e deve ser mantido inalterado.<\/div><\/div><div id=\"field_3_27\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"258d3b03\" data-field-span=\"12\"><\/li>\n<\/ul>\n<ol class='gform_fields top_label description_below'>\n<li class=\"gform_hidden\" value=\"0\">\n<\/div><div id=\"field_3_20\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"45c8acae\" data-field-span=\"12\">Dear Sir or Madam,\n<br>\n<br>\nThis letter agreement (the agreement) confirms the terms on which I agree to allow,(i) Solta Medical Ireland\nLimited, a Bausch Health company, with a place of business at 3013 Lake Drive, Citywest Business Campus,\nDublin 24, Ireland, and its affiliates (together the Companies) to use, Clinic\u2019s name, logo, and\/or practice contact details of<\/div><div id=\"field_3_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-five-twelfths field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"8cc43853\" data-field-span=\"5\"><label id='gfield_label_3_1' class='gfield_label gform-field-label' for='input_3_1'><span class='gform-field-label__text'>Clinic Name:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_3_1' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div data-field-id=\"1\" class=\"spacer gfield\" style=\"grid-column: span 7;\" data-group-id=\"8cc43853\"><\/div><div id=\"field_3_23\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"82138dba\" data-field-span=\"12\">for the purposes set out below.\n<br>\n<br><ol><li>\nthe CLINIC hereby grants to each of the Companies the express right to use the name of the CLINIC,\nthe contact details of the CLINIC (main contact person, address, telephone, e-mail and\/or website)\nand\/or the logo of the CLINIC as listed in the Annex (hereinafter \"DATA\") on the following websites\n\tof each of the Companies in connection with Solta Medical's products (hereinafter \"Websites\"):<\/div><div id=\"field_3_24\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"9f0703d7\" data-field-span=\"12\"><li><a href=\"http:\/\/www.soltamedical.com\/\">www.soltamedical.com<\/a><\/li>\n<li><a href=\"http:\/\/www.fraxel.de\/\">www.fraxel.de<\/a><\/li>\n<li><a href=\"http:\/\/www.thermage.de\/\">www.thermage.de<\/a><\/li>\n<li><a href=\"http:\/\/www.clearandbrilliant.de\">www.clearandbrilliant.de<\/a><\/li>\n<li><a href=\"http:\/\/www.vaser.de\/\">www.vaser.de<\/a><\/li>\n<li><a href=\"http:\/\/www.reaffirmage.es\/\">www.reaffirmage.es<\/a><\/li>\n<li><a href=\"http:\/\/www.soltamedical.de\/\">www.soltamedical.de<\/a><\/li>\n<li><a href=\"http:\/\/www.fraxel.com\/\">www.fraxel.com<\/a><\/li>\n<li><a href=\"http:\/\/www.thermage.com\/\">www.thermage.com<\/a><\/li>\n<li><a href=\"http:\/\/www.dearandbrilllant.com\/\">www.dearandbrilllant.com<\/a><\/li>\n<li><a href=\"http:\/\/www.vaser.com\/\">www.vaser.com<\/a><\/li>\n<li><a href=\"http:\/\/www.reaffirmage.it\/\">www.reaffirmage.it<\/a><\/li>\n<li><a href=\"http:\/\/www.soltamedical.co.uk\/\">www.soltamedical.co.uk<\/a><\/li>\n<li><a href=\"http:\/\/www.fraxel.co.uk\/\">www.fraxel.co.uk<\/a><\/li>\n<li><a href=\"http:\/\/www.thermage.co.uk\/\">www.thermage.co.uk<\/a><\/li>\n<li><a href=\"http:\/\/www.clearandbrilliant.co.uk\/\">www.clearandbrilliant.co.uk<\/a><\/li>\n<li><a href=\"http:\/\/www.vaser.co.uk\/\">www.vaser.co.uk<\/a><\/li>\n<li><a href=\"http:\/\/www.reaffirmage.pt\/\">www.reaffirmage.pt<\/a><\/li>\n<li><a href=\"http:\/\/www.soltamedical.es\/\">www.soltamedical.es<\/a><\/li>\n<li><a href=\"http:\/\/www.fraxel.es\/\">www.fraxel.es<\/a><\/li>\n<li><a href=\"http:\/\/www.thermage.es\/\">www.thermage.es<\/a><\/li>\n<li><a href=\"http:\/\/www.clearandbrilliant.es\/\">www.clearandbrilliant.es<\/a><\/li>\n<li><a href=\"http:\/\/www.vaser.es\/\">www.vaser.es<\/a><\/li>\n<li><a href=\"http:\/\/www.soltamedical.fr\/\">www.soltamedical.fr<\/a><\/li>\n<li><a href=\"http:\/\/www.fraxel.fr\/\">www.fraxel.fr<\/a><\/li>\n<li><a href=\"http:\/\/www.thermage.fr\/\">www.thermage.fr<\/a><\/li>\n<li><a href=\"http:\/\/www.clearandbrilliant.fr\/\">www.clearandbrilliant.fr<\/a><\/li>\n<li><a href=\"http:\/\/www.vaser.fr\/\">www.vaser.fr<\/a><\/li>\n<li><a href=\"http:\/\/www.soltamedical.it\/\">www.soltamedical.it<\/a><\/li>\n<li><a href=\"http:\/\/www.fraxel.it\/\">www.fraxel.it<\/a><\/li>\n<li><a href=\"http:\/\/www.thermage.it\/\">www.thermage.it<\/a><\/li>\n<li><a href=\"http:\/\/www.clearandbrilliant.it\/\">www.clearandbrilliant.it<\/a><\/li>\n<li><a href=\"http:\/\/www.vaser.it\/\">www.vaser.it<\/a><\/li>\n<li><a href=\"http:\/\/www.soltamedical.ch\/\">www.soltamedical.ch<\/a><\/li>\n<li><a href=\"http:\/\/www.fraxel.ch\/\">www.fraxel.ch<\/a><\/li>\n<li><a href=\"http:\/\/www.thermage.ch\/\">www.thermage.ch<\/a><\/li>\n<li><a href=\"http:\/\/www.clearandbrilliant.ch\/\">www.clearandbrilliant.ch<\/a><\/li>\n<li><a href=\"http:\/\/www.vaser.ch\/\">www.vaser.ch<\/a><\/li>\n<li><a href=\"http:\/\/www.soltamedical.at\/\">www.soltamedical.at<\/a><\/li>\n<li><a href=\"http:\/\/www.fraxel.at\/\">www.fraxel.at<\/a><\/li>\n<li><a href=\"http:\/\/www.thermage.at\/\">www.thermage.at<\/a><\/li>\n<li><a href=\"http:\/\/www.clearandbrilliant.at\/\">www.clearandbrilliant.at<\/a><\/li>\n<li><a href=\"http:\/\/www.vaser.at\/\">www.vaser.at<\/a><\/li><a href=\"http:\/\/www.myvaser.com\/\">www.myvaser.com<\/a><\/li><\/div><div id=\"field_3_22\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"3af32ee8\" data-field-span=\"12\"><ul>The DATA on the Websites is used solely to identify the CLINIC as a customer of the Companies and as the practice\/clinic where Solta Medical's products are available. Except as expressly provided herein, neither CLINIC nor the Companies may use each other's names or trademarks without the other's prior written permission.<\/ul><br>\n\n<ol start=\"2\"><li>Each of the company will:\n<ol TYPE=\"a\"><li>Comply with the requirements of all applicable laws and regulations with respect to the use of theDATA and any related personal data; and<\/li>\n<li>Process the DATA and any related personal data in accordance with the Privacy Statements on theWebsites, available at https:\/\/www.bauschhealth.com\/privacy-policy, as amended from time to time.<\/li><\/ol><\/li><\/ul><\/div><fieldset id=\"field_3_21\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"d31208e5\" data-field-span=\"12\"><legend id='gfield_label_3_21' class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class='gform-field-label__text'><\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_21.1' id='input_3_21_1' type='checkbox' value='1'   aria-labelledby=\"input_3_21_1_label gfield_label_3_21\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label id='input_3_21_1_label' class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_21_1' ><span class='gform-field-label__text'>I have read and agree to the privacy policy.<\/span><\/label><input type='hidden' name='input_21.2' value='I have read and agree to the privacy policy.' class='gform_hidden' \/><input type='hidden' name='input_21.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_3_25\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"a5e8f717\" data-field-span=\"12\"><ol start=\"3\"><li>Any of the Companies shall have the right to assign this Declaration by merger, acquisition, partnership, license agreement, assignment agreement or otherwise to any third party or affiliate or successor in interest.<\/li><br>\n<li>This declaration of consent can be revoked at any time with effect for the future at infoEMEA@solta.com . In case of revocation, the DATA will be removed from the relevant website. If the DATA were available on the Internet, the removal takes place as far as it is subject to the disposal possibilities of the company.<\/li><br>\n<li>All Vaser surgeons in the United Kingdom and Ireland must be a member of one of the four Royal College of Surgeons (London, Edinburgh and Glasgow) and Ireland (Dublin) to be eligible to be entered in the clinic finder<\/li><br>\n<li>This Declaration and any dispute or claim (including non-contractual disputes or claims) arising out of or in connection with it or its subject matter shall be governed by and construed in accordance with the laws of Ireland.<\/li><br>\n<li>The courts of Ireland shall have exclusive jurisdiction to settle any dispute or claim (including any non-contractual disputes or claims) arising out of or in connection with this Declaration or its subject matter or formation<\/ol><\/li><\/div><div id=\"field_3_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"e15685cb\" data-field-span=\"6\"><label id='gfield_label_3_28' class='gfield_label gform-field-label' for='input_3_28'><span class='gform-field-label__text'>Name [NAME OF THE Managing Director]<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_3_28' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_29\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"e15685cb\" data-field-span=\"6\"><label id='gfield_label_3_29' class='gfield_label gform-field-label' for='input_3_29'><span class='gform-field-label__text'>Signature<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_29' id='input_3_29_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_29_Container' class='gfield_signature_container ginput_container' style='height:180px; width:500px; ' ><canvas id='input_3_29' width='500' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/mysolta.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_3_29_toolbar' style='margin:5px 0;position:relative;height:20px;width:500px;max-width:100%;'><img id = 'input_3_29_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_3_29_data' name='input_3_29_data' value=''><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <button type='button' id='gform_next_button_3_26' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_2' class='gform_page' data-js='page-field-id-26' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_2' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><fieldset id=\"field_3_7\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"0579ff38\" data-field-span=\"12\"><legend id='gfield_label_3_7' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_3_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_3_7_1' value=''    aria-required='false'    aria-labelledby=\"input_3_7_1_label gfield_label_3_7\"\/>\n                                        <label for='input_3_7_1' id='input_3_7_1_label' class='gform-field-label gform-field-label--type-sub '>Endere\u00e7o<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_7_2_container' >\n                                        <input type='text' name='input_7.2' id='input_3_7_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_7_2' id='input_3_7_2_label' class='gform-field-label gform-field-label--type-sub '>Endere\u00e7o linha 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_3_7_3' value=''    aria-required='false'    \/>\n                                    <label for='input_3_7_3' id='input_3_7_3_label' class='gform-field-label gform-field-label--type-sub '>Cidade<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_7_4_container' >\n                                        <input type='text' name='input_7.4' id='input_3_7_4' value=''      aria-required='false'    \/>\n                                        <label for='input_3_7_4' id='input_3_7_4_label' class='gform-field-label gform-field-label--type-sub '>Estado \/ Prov\u00edncia \/ Regi\u00e3o<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_3_7_5' value=''    aria-required='false'    \/>\n                                    <label for='input_3_7_5' id='input_3_7_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_3_7_6_container' >\n                                        <select name='input_7.6' id='input_3_7_6'   aria-required='false'    ><option value='' ><\/option><option value='AF' >Afeganist\u00e3o<\/option><option value='ZA' >\u00c1frica do Sul<\/option><option value='AL' >Alb\u00e2nia<\/option><option value='DE' >Alemanha<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Ant\u00e1rtida<\/option><option value='AG' >Ant\u00edgua e Barbuda<\/option><option value='SA' >Ar\u00e1bia Saudita<\/option><option value='DZ' >Arg\u00e9lia<\/option><option value='AR' >Argentina<\/option><option value='AM' >Arm\u00e9nia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Austr\u00e1lia<\/option><option value='AT' >\u00c1ustria<\/option><option value='AZ' >Azerbeij\u00e3o<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BE' >B\u00e9lgica<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermudas<\/option><option value='BY' >Bielorr\u00fassia<\/option><option value='MM' >Birm\u00e2nia<\/option><option value='BO' >Bol\u00edvia<\/option><option value='BQ' >Bonaire, Santo Eust\u00e1quio e Saba<\/option><option value='BA' >B\u00f3snia e Hezergovina<\/option><option value='BW' >Botsuana<\/option><option value='BR' >Brasil<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulg\u00e1ria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='BT' >But\u00e3o<\/option><option value='CV' >Cabo Verde<\/option><option value='CM' >Camar\u00f5es<\/option><option value='KH' >Cambodja<\/option><option value='CA' >Canad\u00e1<\/option><option value='KZ' >Cazaquist\u00e3o<\/option><option value='TD' >Chade<\/option><option value='CZ' >Ch\u00e9quia<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CY' >Chipre<\/option><option value='CO' >Col\u00f4mbia<\/option><option value='KM' >Comores<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Rep\u00fablica Democr\u00e1tica<\/option><option value='KR' >Coreia, Rep\u00fablica da<\/option><option value='KP' >Coreia, Rep\u00fablica Popular da<\/option><option value='CI' >Costa do Marfim<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Cro\u00e1cia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7\u00e3o<\/option><option value='DK' >Dinamarca<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='EG' >Egito<\/option><option value='SV' >El Salvador<\/option><option value='AE' >Emirados \u00c1rabes Unidos<\/option><option value='EC' >Equador<\/option><option value='ER' >Eritreia<\/option><option value='SK' >Eslov\u00e1quia<\/option><option value='SI' >Eslov\u00e9nia<\/option><option value='ES' >Espanha<\/option><option value='SZ' >Essuat\u00edni<\/option><option value='PS' >Estado da Palestina<\/option><option value='US' >Estados Unidos<\/option><option value='EE' >Est\u00f3nia<\/option><option value='ET' >Eti\u00f3pia<\/option><option value='RU' >Federa\u00e7\u00e3o Russa<\/option><option value='FJ' >Fiji<\/option><option value='PH' >Filipinas<\/option><option value='FI' >Finl\u00e2ndia<\/option><option value='FR' >Fran\u00e7a<\/option><option value='GA' >Gab\u00e3o<\/option><option value='GM' >G\u00e2mbia<\/option><option value='GH' >Gana<\/option><option value='GE' >Ge\u00f3rgia<\/option><option value='GI' >Gibraltar<\/option><option value='GD' >Granada<\/option><option value='GR' >Gr\u00e9cia<\/option><option value='GL' >Gronel\u00e2ndia<\/option><option value='GP' >Guadalupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GY' >Guiana<\/option><option value='GF' >Guiana Francesa<\/option><option value='GN' >Guin\u00e9<\/option><option value='GQ' >Guin\u00e9 Equatorial<\/option><option value='GW' >Guin\u00e9-Bissau<\/option><option value='HT' >Haiti<\/option><option value='NL' >Holanda<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungria<\/option><option value='YE' >I\u00eamen<\/option><option value='BV' >Ilha Bouvet<\/option><option value='IM' >Ilha de Man<\/option><option value='CX' >Ilha do Natal<\/option><option value='HM' >Ilha Heard e Ilhas McDonald<\/option><option value='NF' >Ilha Norfolk<\/option><option value='KY' >Ilhas Caim\u00e3o<\/option><option value='CC' >Ilhas Cocos<\/option><option value='CK' >Ilhas Cook<\/option><option value='AX' >Ilhas de Alanda<\/option><option value='FO' >Ilhas Faro\u00e9<\/option><option value='GS' >Ilhas Ge\u00f3rgia do Sul e Sandwich do Sul<\/option><option value='FK' >Ilhas Malvinas<\/option><option value='MP' >Ilhas Marianas do Norte<\/option><option value='MH' >Ilhas Marshall<\/option><option value='MU' >Ilhas Maur\u00edcias<\/option><option value='UM' >Ilhas Menores Afastadas dos Estados Unidos<\/option><option value='SB' >Ilhas Salom\u00e3o<\/option><option value='TC' >Ilhas Turcas e Caicos<\/option><option value='VG' >Ilhas Virgens Brit\u00e2nicas<\/option><option value='VI' >Ilhas Virgens, EUA<\/option><option value='IN' >\u00cdndia<\/option><option value='ID' >Indon\u00e9sia<\/option><option value='IR' >Ir\u00e3o<\/option><option value='IQ' >Iraque<\/option><option value='IE' >Irlanda<\/option><option value='IS' >Isl\u00e2ndia<\/option><option value='IL' >Israel<\/option><option value='IT' >It\u00e1lia<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Jap\u00e3o<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jord\u00e2nia<\/option><option value='KI' >Kiribati<\/option><option value='KW' >Kuwait<\/option><option value='LA' >Laos<\/option><option value='LS' >Lesoto<\/option><option value='LV' >Let\u00f3nia<\/option><option value='LB' >L\u00edbano<\/option><option value='LR' >Lib\u00e9ria<\/option><option value='LY' >L\u00edbia<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Litu\u00e2nia<\/option><option value='LU' >Luxemburgo<\/option><option value='MO' >Macau<\/option><option value='MK' >Maced\u00f3nia do Norte<\/option><option value='MG' >Madag\u00e1scar<\/option><option value='MY' >Mal\u00e1sia<\/option><option value='MW' >Malawi<\/option><option value='MV' >Maldivas<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MA' >Marrocos<\/option><option value='MQ' >Martinica<\/option><option value='MR' >Maurit\u00e2nia<\/option><option value='YT' >Mayotte<\/option><option value='MX' >M\u00e9xico<\/option><option value='FM' >Micron\u00e9sia<\/option><option value='MZ' >Mo\u00e7ambique<\/option><option value='MD' >Mold\u00e1via<\/option><option value='MC' >M\u00f3naco<\/option><option value='MN' >Mong\u00f3lia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='NA' >Nam\u00edbia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NI' >Nicar\u00e1gua<\/option><option value='NE' >N\u00edger<\/option><option value='NG' >Nig\u00e9ria<\/option><option value='NU' >Niue<\/option><option value='NO' >Noruega<\/option><option value='NC' >Nova Caled\u00f3nia<\/option><option value='NZ' >Nova Zel\u00e2ndia<\/option><option value='OM' >Om\u00e3<\/option><option value='PW' >Palau<\/option><option value='PA' >Panam\u00e1<\/option><option value='PG' >Papua Nova Guin\u00e9<\/option><option value='PK' >Paquist\u00e3o<\/option><option value='PY' >Paraguai<\/option><option value='PE' >Per\u00fa<\/option><option value='PN' >Pitcairn<\/option><option value='PF' >Polin\u00e9sia francesa<\/option><option value='PL' >Pol\u00f3nia<\/option><option value='PR' >Porto Rico<\/option><option value='PT' >Portugal<\/option><option value='QA' >Qatar<\/option><option value='KE' >Qu\u00e9nia<\/option><option value='KG' >Quirguist\u00e3o<\/option><option value='GB' >Reino Unido<\/option><option value='CF' >Rep\u00fablica Centro Africana<\/option><option value='DO' >Rep\u00fablica Dominicana<\/option><option value='RE' >Reuni\u00e3o<\/option><option value='RO' >Rom\u00e9nia<\/option><option value='RW' >Ruanda<\/option><option value='MF' >Saint Martin<\/option><option value='WS' >Samoa<\/option><option value='AS' >Samoa Americana<\/option><option value='SH' >Santa Helena, Ascens\u00e3o e Trist\u00e3o da Cunha<\/option><option value='LC' >Santa L\u00facia<\/option><option value='VA' >Santa S\u00e9<\/option><option value='BL' >S\u00e3o Bartolomeu<\/option><option value='KN' >S\u00e3o Crist\u00f3v\u00e3o e N\u00e9vis<\/option><option value='SM' >S\u00e3o Marino<\/option><option value='SX' >S\u00e3o Martinho<\/option><option value='PM' >S\u00e3o Pedro e Miguel\u00e3o<\/option><option value='ST' >S\u00e3o Tom\u00e9 e Pr\u00edncipe<\/option><option value='VC' >S\u00e3o Vicente e Granadinas<\/option><option value='EH' >Sara Ocidental<\/option><option value='SC' >Seicheles<\/option><option value='SN' >Senegal<\/option><option value='SL' >Serra Leoa<\/option><option value='RS' >S\u00e9rvia<\/option><option value='SG' >Singapura<\/option><option value='SY' >S\u00edria, Rep\u00fablica \u00c1rabe<\/option><option value='SO' >Som\u00e1lia<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sud\u00e3o<\/option><option value='SS' >Sud\u00e3o do Sul<\/option><option value='SE' >Su\u00e9cia<\/option><option value='CH' >Su\u00ed\u00e7a<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard e Jan Mayen<\/option><option value='TJ' >Tadjiquist\u00e3o<\/option><option value='TH' >Tail\u00e2ndia<\/option><option value='TW' >Taiwan<\/option><option value='TZ' >Tanz\u00e2nia, Rep\u00fablica Unida da<\/option><option value='TF' >Terras Austrais e Ant\u00e1rticas Francesas<\/option><option value='IO' >Territ\u00f3rio Brit\u00e2nico do Oceano \u00cdndico<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TO' >Tonga<\/option><option value='TK' >Toquelao<\/option><option value='TT' >Trinidade e Tobago<\/option><option value='TN' >Tun\u00edsia<\/option><option value='TM' >Turquemenist\u00e3o<\/option><option value='TR' >Turquia<\/option><option value='TV' >Tuvalu<\/option><option value='UA' >Ucr\u00e2nia<\/option><option value='UG' >Uganda<\/option><option value='UY' >Uruguai<\/option><option value='UZ' >Uzbequist\u00e3o<\/option><option value='VU' >Vanuatu<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietname<\/option><option value='WF' >Wallis e Futuna<\/option><option value='ZM' >Z\u00e2mbia<\/option><option value='ZW' >Zimbabue<\/option><\/select>\n                                        <label for='input_3_7_6' id='input_3_7_6_label' class='gform-field-label gform-field-label--type-sub '>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><input type=\"hidden\" name=\"gpaa_place_7\" class=\"gform_hidden\" value=\"\"><\/fieldset><div id=\"field_3_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"82526a89\" data-field-span=\"12\"><label id='gfield_label_3_3' class='gfield_label gform-field-label' for='input_3_3'><span class='gform-field-label__text'>Name of the Clinic&#039;s Contact Person:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_3_3' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"9f133df7\" data-field-span=\"12\"><label id='gfield_label_3_4' class='gfield_label gform-field-label' for='input_3_4'><span class='gform-field-label__text'>Name of the Doctor:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_3_4' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_8\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"60971ba7\" data-field-span=\"12\"><label id='gfield_label_3_8' class='gfield_label gform-field-label' for='input_3_8'><span class='gform-field-label__text'>Phone Number of the Clinic:<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_3_8' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_9\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"9ada1c8d\" data-field-span=\"12\"><label id='gfield_label_3_9' class='gfield_label gform-field-label' for='input_3_9'><span class='gform-field-label__text'>Email Address of the Clinic:<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_9' id='input_3_9' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"a43222ba\" data-field-span=\"12\"><label id='gfield_label_3_5' class='gfield_label gform-field-label' for='input_3_5'><span class='gform-field-label__text'>Opening Hours<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_3_5' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_30\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"1b392d13\" data-field-span=\"12\"><label id='gfield_label_3_30' class='gfield_label gform-field-label' for='input_3_30'><span class='gform-field-label__text'>Clinic Description<\/span><\/label><div class='ginput_container ginput_container_textarea' data-text-counter-max='500' data-text-counter-template='{current} of {max} max characters'><textarea name='input_30' id='input_3_30' class='textarea large'  aria-describedby=\"gfield_description_3_30\" maxlength='500'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_3_30'>If not filled in, the content will be taken from the website.<\/div><\/div><div id=\"field_3_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"530222d9\" data-field-span=\"12\"><label id='gfield_label_3_6' class='gfield_label gform-field-label' for='input_3_6'><span class='gform-field-label__text'>Website Clinic:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_3_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_10\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"fe1b3b2e\" data-field-span=\"12\"><label id='gfield_label_3_10' class='gfield_label gform-field-label' for='input_3_10'><span class='gform-field-label__text'>Logo Clinic:<\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='52428800' \/><input name='input_10' id='input_3_10' type='file' class='large' aria-describedby=\"gfield_upload_rules_3_10 gfield_description_3_10\" onchange='javascript:gformValidateFileSize( this, 52428800 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_3_10'>Tipos de ficheiro aceites: jpg, gif, png, pdf, Tamanho m\u00e1x. de ficheiro: 50 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_3_10'><\/div> <\/div><div class='gfield_description' id='gfield_description_3_10'>If not uploaded, the logo will be taken from the website.<\/div><\/div><fieldset id=\"field_3_12\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"cde56602\" data-field-span=\"12\"><legend id='gfield_label_3_12' class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class='gform-field-label__text'><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_12'><div class='gchoice gchoice_3_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='Thermage\u00ae FLX'  id='choice_3_12_1'    aria-labelledby=\"label_3_12_1 gfield_label_3_12\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_12_1' id='label_3_12_1' class='gform-field-label gform-field-label--type-inline'>Thermage\u00ae FLX<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='Fraxel\u00ae DUAL (former Fraxel re:store DUAL)'  id='choice_3_12_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_12_2' id='label_3_12_2' class='gform-field-label gform-field-label--type-inline'>Fraxel\u00ae DUAL (former Fraxel re:store DUAL)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='Clear + Brilliant\u00ae'  id='choice_3_12_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_12_3' id='label_3_12_3' class='gform-field-label gform-field-label--type-inline'>Clear + Brilliant\u00ae<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_12_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.4' type='checkbox'  value='VASER\u00ae:'  id='choice_3_12_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_12_4' id='label_3_12_4' class='gform-field-label gform-field-label--type-inline'>VASER\u00ae:<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"b1c5d473\" data-field-span=\"12\"><label id='gfield_label_3_13' class='gfield_label gform-field-label' for='input_3_13'><span class='gform-field-label__text'>Thermage\u00ae FLX Serial No.:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_3_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"879b536b\" data-field-span=\"12\"><label id='gfield_label_3_14' class='gfield_label gform-field-label' for='input_3_14'><span class='gform-field-label__text'>Fraxel\u00ae DUAL (former Fraxel re:store DUAL)Serial No.:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_3_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"2b887bc3\" data-field-span=\"12\"><label id='gfield_label_3_15' class='gfield_label gform-field-label' for='input_3_15'><span class='gform-field-label__text'>Clear + Brilliant\u00ae Serial No.:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_3_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"dd2eae0f\" data-field-span=\"12\"><label id='gfield_label_3_16' class='gfield_label gform-field-label' for='input_3_16'><span class='gform-field-label__text'>VASER\u00ae Serial No.:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_3_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_32\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"764a9c56\" data-field-span=\"12\"><legend id='gfield_label_3_32' class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class='gform-field-label__text'><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_32.1' id='input_3_32_1' type='checkbox' value='1'   aria-labelledby=\"input_3_32_1_label gfield_label_3_32\"  aria-invalid=\"false\"   \/> <label id='input_3_32_1_label' class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_32_1' ><span class='gform-field-label__text'>I would like to be contacted by Solta Medical a Bausch Health Company about promotions, news and events in the future. This declaration of consent can be revoked at any time with effect for the future at <ahref =\"mailto:InfoEMEA@solta.com\">I would like to be contacted by Solta Medical a Bausch Health Company about promotions, news and events in the future. This declaration of consent can be revoked at any time with effect for the future at InfoEMEA@solta.com<\/a><\/span><\/label><input type='hidden' name='input_32.2' value='I would like to be contacted by Solta Medical a Bausch Health Company about promotions, news and events in the future. This declaration of consent can be revoked at any time with effect for the future at &lt;ahref =&quot;mailto:InfoEMEA@solta.com&quot;&gt;I would like to be contacted by Solta Medical a Bausch Health Company about promotions, news and events in the future. 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