<div class='gf_browser_gecko gform_wrapper gravity-theme' id='gform_wrapper_1' ><div id='gf_1' class='gform_anchor' tabindex='-1'></div><form method='post' enctype='multipart/form-data' id='gform_1' action='/category/patients/#gf_1' novalidate> <div class='gform_body gform-body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><div id="field_1_1" class="gfield gfield--width-half gf_left_half gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_1"><label class='gfield_label screen-reader-text' for='input_1_1' >First Name</label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_1_1' type='text' value='' class='large' placeholder='First Name' aria-invalid="false" /> </div></div><div id="field_1_3" class="gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_3"><label class='gfield_label screen-reader-text' for='input_1_3' >Last Name</label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='text' value='' class='large' placeholder='Last Name' aria-invalid="false" /> </div></div><div id="field_1_8" class="gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_8"><label class='gfield_label screen-reader-text' for='input_1_8' >Country</label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='large' placeholder='Country' aria-invalid="false" /> </div></div><div id="field_1_4" class="gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_4"><label class='gfield_label screen-reader-text' for='input_1_4' >Email Address</label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='large' placeholder='Email Address' aria-invalid="false" /> </div></div><div id="field_1_7" class="gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_7"><label class='gfield_label screen-reader-text' for='input_1_7' >Message</label><div class='ginput_container ginput_container_textarea'><textarea name='input_7' id='input_1_7' class='textarea large' placeholder='Message' aria-invalid="false" rows='10' cols='50'></textarea></div></div><div id="field_1_9" class="gfield gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_9">By submitting, I consent to receive content from Mercy Ships in accordance with their <a href="#">Privacy Policy</a>.</div><div id="field_submit" class="gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible" data-field-class="gform_editor_submit_container" data-field-position="inline" data-js-reload="true"><input type='submit' id='gform_submit_button_1' class='gform-button gform-button--white button' value='Submit' onclick='if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} jQuery("#gform_1").trigger("submit",[true]); }' /></div></div></div> <div class='gform_footer top_label'> <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='1' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_1' value='WyJbXSIsIjQ4NDBhNjRiMTY5ZThhNjBjODgzYTkxYTk0MmQxNjgwIl0=' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> </form> </div>