{"id":542,"date":"2019-08-07T07:07:30","date_gmt":"2019-08-07T07:07:30","guid":{"rendered":"https:\/\/www.fibroids.co.za\/?page_id=542"},"modified":"2026-03-21T23:24:27","modified_gmt":"2026-03-21T21:24:27","slug":"contact","status":"publish","type":"page","link":"https:\/\/www.fibroids.co.za\/pt\/contact\/","title":{"rendered":"Contact"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; custom_padding_last_edited=&#8221;on|phone&#8221; module_class=&#8221;inner_banners&#8221; _builder_version=&#8221;4.16&#8243; background_image=&#8221;https:\/\/www.fibroids.co.za\/wp-content\/uploads\/2019\/08\/banner-bg-3.jpg&#8221; custom_padding=&#8221;58px||58px|&#8221; custom_padding_tablet=&#8221;&#8221; custom_padding_phone=&#8221;0px||0px|&#8221; background_last_edited=&#8221;on|phone&#8221; z_index_tablet=&#8221;500&#8243; box_shadow_horizontal_tablet=&#8221;0px&#8221; box_shadow_vertical_tablet=&#8221;0px&#8221; box_shadow_blur_tablet=&#8221;40px&#8221; 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gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_1' ><style>#gform_wrapper_1[data-form-index=\"0\"].gform-theme,[data-parent-form=\"1_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: #585e6a;--gf-color-out-ctrl-dark-rgb: 88, 94, 106;--gf-color-out-ctrl-dark-darker: #112337;--gf-color-out-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-color-in-ctrl: #fff;--gf-color-in-ctrl-rgb: 255, 255, 255;--gf-color-in-ctrl-contrast: #112337;--gf-color-in-ctrl-contrast-rgb: 17, 35, 55;--gf-color-in-ctrl-darker: #F5F5F5;--gf-color-in-ctrl-lighter: #FFFFFF;--gf-color-in-ctrl-primary: #204ce5;--gf-color-in-ctrl-primary-rgb: 32, 76, 229;--gf-color-in-ctrl-primary-contrast: #fff;--gf-color-in-ctrl-primary-contrast-rgb: 255, 255, 255;--gf-color-in-ctrl-primary-darker: #001AB3;--gf-color-in-ctrl-primary-lighter: #527EFF;--gf-color-in-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-in-ctrl-light-rgb: 17, 35, 55;--gf-color-in-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-in-ctrl-light-lighter: #F5F5F5;--gf-color-in-ctrl-dark: #585e6a;--gf-color-in-ctrl-dark-rgb: 88, 94, 106;--gf-color-in-ctrl-dark-darker: #112337;--gf-color-in-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-radius: 3px;--gf-font-size-secondary: 14px;--gf-font-size-tertiary: 13px;--gf-icon-ctrl-number: url(\"data:image\/svg+xml,%3Csvg width='8' height='14' viewBox='0 0 8 14' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-select: url(\"data:image\/svg+xml,%3Csvg width='10' height='6' viewBox='0 0 10 6' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg width='640' height='640' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #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-file-btn-bg-color-hover: #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_1' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\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' target='gform_ajax_frame_1' id='gform_1'  action='\/pt\/wp-json\/wp\/v2\/pages\/542#gf_1' data-formid='1' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LeixJ0pAAAAADhk9aCgTEYFE7bYj9df-0DFALWi' data-tabindex='49'><input id=\"input_2d7a60f2b919364ce096d6d4aeca9888\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_2d7a60f2b919364ce096d6d4aeca9888\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_9\" 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\"  ><p>All questions contained in this questionnaire are strictly confidential and will become part of your medical record.<\/p><\/div><fieldset id=\"field_1_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value='' tabindex='51'  aria-required='true'     \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>Primeiro<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value='' tabindex='53'  aria-required='true'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>\u00daltimo<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_3\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_1_3' type='email' value='' class='large' tabindex='55'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_1_4' type='tel' value='' class='large' tabindex='56'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Medical Aid<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_5' id='input_1_5' class='large gfield_select' tabindex='57'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Do you have medical aid?<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>The treatment you are interested in<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_1_6' class='large gfield_select' tabindex='58'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose a treatment<\/option><option value='Fibroid Treatment' >Fibroid Treatment<\/option><option value='Fallopian Tube Recanalisation' >Fallopian Tube Recanalisation<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><fieldset id=\"field_1_10\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please select the location closest to you<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_10'><div class='gchoice gchoice_1_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Cape Town'  id='choice_1_10_1' tabindex='59'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_10_1' id='label_1_10_1' class='gform-field-label gform-field-label--type-inline'>Cape Town<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='Johannesburg'  id='choice_1_10_2' tabindex='60'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_10_2' id='label_1_10_2' class='gform-field-label gform-field-label--type-inline'>Johannesburg<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_10_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.3' type='checkbox'  value='East London'  id='choice_1_10_3' tabindex='61'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_10_3' id='label_1_10_3' class='gform-field-label gform-field-label--type-inline'>East London<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_10_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.4' type='checkbox'  value='Umhlanga'  id='choice_1_10_4' tabindex='62'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_10_4' id='label_1_10_4' class='gform-field-label gform-field-label--type-inline'>Umhlanga<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_7\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you suffer from any of the following?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_7'><div class='gchoice gchoice_1_7_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.1' type='checkbox'  value='Heavy menstrual bleeding'  id='choice_1_7_1' tabindex='63'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_1' id='label_1_7_1' class='gform-field-label gform-field-label--type-inline'>Heavy menstrual bleeding<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_7_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.2' type='checkbox'  value='Large Abdominal mass'  id='choice_1_7_2' tabindex='64'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_2' id='label_1_7_2' class='gform-field-label gform-field-label--type-inline'>Large Abdominal mass<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_7_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.3' type='checkbox'  value='Infertility'  id='choice_1_7_3' tabindex='65'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_3' id='label_1_7_3' class='gform-field-label gform-field-label--type-inline'>Infertility<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_7_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.4' type='checkbox'  value='Bladder pressure with frequent urination'  id='choice_1_7_4' tabindex='66'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_4' id='label_1_7_4' class='gform-field-label gform-field-label--type-inline'>Bladder pressure with frequent urination<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_7_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.5' type='checkbox'  value='Tiredness\/dizziness'  id='choice_1_7_5' tabindex='67'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_5' id='label_1_7_5' class='gform-field-label gform-field-label--type-inline'>Tiredness\/dizziness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_7_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.6' type='checkbox'  value='Pelvic Pain'  id='choice_1_7_6' tabindex='68'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_6' id='label_1_7_6' class='gform-field-label gform-field-label--type-inline'>Pelvic Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_7_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.7' type='checkbox'  value='Bowel pressure with constipation and bloating'  id='choice_1_7_7' tabindex='69'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_7' id='label_1_7_7' class='gform-field-label gform-field-label--type-inline'>Bowel pressure with constipation and bloating<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_7_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.8' type='checkbox'  value='Back and leg pain'  id='choice_1_7_8' tabindex='70'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_8' id='label_1_7_8' class='gform-field-label gform-field-label--type-inline'>Back and leg pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_7_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.9' type='checkbox'  value='Pain during intercourse'  id='choice_1_7_9' tabindex='71'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_9' id='label_1_7_9' class='gform-field-label gform-field-label--type-inline'>Pain during intercourse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_7_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.11' type='checkbox'  value='Other'  id='choice_1_7_11' tabindex='72'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_11' id='label_1_7_11' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_8\" 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\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Declaration<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_8.1' id='input_1_8_1' type='checkbox' value='1' tabindex='73'  aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_8_1' >I hereby consent to my personal information contained in this form to be transmitted to and used by Dr Gary Sudwarts and Associates Inc. for the purpose of treatment.<\/label><input type='hidden' name='input_8.2' value='I hereby consent to my personal information contained in this form to be transmitted to and used by Dr Gary Sudwarts and Associates Inc. for the purpose of treatment.' class='gform_hidden' \/><input type='hidden' name='input_8.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_1_11\" class=\"gfield 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3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-select: url(\"data:image\/svg+xml,%3Csvg width='10' height='6' viewBox='0 0 10 6' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg width='640' height='640' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #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-file-btn-bg-color-hover: #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_1' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\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' target='gform_ajax_frame_1' id='gform_1'  action='\/pt\/wp-json\/wp\/v2\/pages\/542#gf_1' data-formid='1' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LeixJ0pAAAAADhk9aCgTEYFE7bYj9df-0DFALWi' data-tabindex='49'><input id=\"input_2d7a60f2b919364ce096d6d4aeca9888\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_2d7a60f2b919364ce096d6d4aeca9888\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_9\" 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\"  ><p>All questions contained in this questionnaire are strictly confidential and will become part of your medical record.<\/p><\/div><fieldset id=\"field_1_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value='' tabindex='51'  aria-required='true'     \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>Primeiro<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value='' tabindex='53'  aria-required='true'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>\u00daltimo<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_3\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_1_3' type='email' value='' class='large' tabindex='55'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_1_4' type='tel' value='' class='large' tabindex='56'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Medical Aid<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_5' id='input_1_5' class='large gfield_select' tabindex='57'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Do you have medical aid?<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>The treatment you are interested in<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_1_6' class='large gfield_select' tabindex='58'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose a treatment<\/option><option value='Fibroid Treatment' >Fibroid Treatment<\/option><option value='Fallopian Tube Recanalisation' >Fallopian Tube Recanalisation<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><fieldset id=\"field_1_10\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please select the location closest to you<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_10'><div class='gchoice gchoice_1_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Cape Town'  id='choice_1_10_1' tabindex='59'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_10_1' id='label_1_10_1' class='gform-field-label gform-field-label--type-inline'>Cape Town<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='Johannesburg'  id='choice_1_10_2' tabindex='60'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_10_2' id='label_1_10_2' class='gform-field-label gform-field-label--type-inline'>Johannesburg<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_10_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.3' type='checkbox'  value='East London'  id='choice_1_10_3' tabindex='61'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_10_3' id='label_1_10_3' class='gform-field-label gform-field-label--type-inline'>East London<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_10_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.4' type='checkbox'  value='Umhlanga'  id='choice_1_10_4' tabindex='62'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_10_4' id='label_1_10_4' class='gform-field-label gform-field-label--type-inline'>Umhlanga<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_7\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you suffer from any of the following?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_7'><div class='gchoice gchoice_1_7_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.1' type='checkbox'  value='Heavy menstrual bleeding'  id='choice_1_7_1' tabindex='63'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_1' id='label_1_7_1' class='gform-field-label gform-field-label--type-inline'>Heavy menstrual bleeding<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_7_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.2' type='checkbox'  value='Large Abdominal mass'  id='choice_1_7_2' tabindex='64'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_2' id='label_1_7_2' class='gform-field-label gform-field-label--type-inline'>Large Abdominal mass<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_7_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.3' type='checkbox'  value='Infertility'  id='choice_1_7_3' tabindex='65'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_3' id='label_1_7_3' class='gform-field-label gform-field-label--type-inline'>Infertility<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_7_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.4' type='checkbox'  value='Bladder pressure with frequent urination'  id='choice_1_7_4' tabindex='66'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_4' id='label_1_7_4' class='gform-field-label gform-field-label--type-inline'>Bladder pressure with frequent urination<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_7_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.5' type='checkbox'  value='Tiredness\/dizziness'  id='choice_1_7_5' tabindex='67'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_5' id='label_1_7_5' class='gform-field-label gform-field-label--type-inline'>Tiredness\/dizziness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_7_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.6' type='checkbox'  value='Pelvic Pain'  id='choice_1_7_6' tabindex='68'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_6' id='label_1_7_6' class='gform-field-label gform-field-label--type-inline'>Pelvic Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_7_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.7' type='checkbox'  value='Bowel pressure with constipation and bloating'  id='choice_1_7_7' tabindex='69'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_7' id='label_1_7_7' class='gform-field-label gform-field-label--type-inline'>Bowel pressure with constipation and bloating<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_7_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.8' type='checkbox'  value='Back and leg pain'  id='choice_1_7_8' tabindex='70'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_8' id='label_1_7_8' class='gform-field-label gform-field-label--type-inline'>Back and leg pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_7_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.9' type='checkbox'  value='Pain during intercourse'  id='choice_1_7_9' tabindex='71'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_9' id='label_1_7_9' class='gform-field-label gform-field-label--type-inline'>Pain during intercourse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_7_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.11' type='checkbox'  value='Other'  id='choice_1_7_11' tabindex='72'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_7_11' id='label_1_7_11' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_8\" 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\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Declaration<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_8.1' id='input_1_8_1' type='checkbox' value='1' tabindex='73'  aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_8_1' >I hereby consent to my personal information contained in this form to be transmitted to and used by Dr Gary Sudwarts and Associates Inc. for the purpose of treatment.<\/label><input type='hidden' name='input_8.2' value='I hereby consent to my personal information contained in this form to be transmitted to and used by Dr Gary Sudwarts and Associates Inc. for the purpose of treatment.' class='gform_hidden' \/><input type='hidden' name='input_8.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_1_11\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div 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