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option\">Book Health Check<\/label>\n      <\/div>\n<div class=\"js-form-item form-item js-form-type-radio form-item__request-type js-form-item-request-type\">\n        <input class=\"request-type-field form-radio form-input\" data-drupal-selector=\"edit-request-type-second-opinion\" type=\"radio\" id=\"edit-request-type-second-opinion\" name=\"request_type\" value=\"second_opinion\" \/>\n\n        <label for=\"edit-request-type-second-opinion\" class=\"form-label option\">Book Second Opinion<\/label>\n      <\/div>\n<\/div>\n\n          <\/div>\n<\/fieldset>\n<\/div>\n<div class=\"lower_container form-container js-form-wrapper form-wrapper\" data-drupal-selector=\"edit-lower-container\" id=\"edit-lower-container\"><div id=\"city-select2-element-wrapper\"><div class=\"js-form-item form-item js-form-type-select form-item__city js-form-item-city form-no-label\">\n        <select data-drupal-selector=\"edit-city\" id=\"edit-city\" name=\"city\" class=\"form-select select2-widget\" data-select2-config=\"{&quot;multiple&quot;:false,&quot;placeholder&quot;:&quot;Select City&quot;,&quot;allowClear&quot;:true,&quot;dir&quot;:&quot;ltr&quot;,&quot;language&quot;:&quot;en&quot;,&quot;tags&quot;:false,&quot;theme&quot;:&quot;default&quot;,&quot;maximumSelectionLength&quot;:0,&quot;tokenSeparators&quot;:[],&quot;selectOnClose&quot;:false,&quot;width&quot;:&quot;100%&quot;,&quot;dropdownParent&quot;:&quot;#city-select2-element-wrapper&quot;}\"><option class=\"form-select__option\" value=\"\" selected=\"selected\"><\/option><option class=\"form-select__option\" value=\"2761\">Ahmedabad<\/option><option class=\"form-select__option\" value=\"3015\">Bangalore<\/option><option class=\"form-select__option\" value=\"3633\">Bhopal<\/option><option class=\"form-select__option\" value=\"4199\">Bhubaneswar<\/option><option class=\"form-select__option\" value=\"6373\">Bilaspur<\/option><option class=\"form-select__option\" value=\"1\">Chennai<\/option><option 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class=\"form-select__option\" value=\"3999\">Nasik<\/option><option class=\"form-select__option\" value=\"1223\">Nellore<\/option><option class=\"form-select__option\" value=\"6009\">Noida<\/option><option class=\"form-select__option\" value=\"4343\">Rourkela<\/option><option class=\"form-select__option\" value=\"5641\">Trichy<\/option><option class=\"form-select__option\" value=\"1983\">Visakhapatnam<\/option><\/select>\n        <\/div>\n<\/div><div class=\"focused-label js-form-item form-item js-form-type-textfield form-item__name js-form-item-name\">\n      <label for=\"edit-name\" class=\"form-label\">Enter Name<\/label>\n        <input data-drupal-selector=\"edit-name\" type=\"text\" id=\"edit-name\" name=\"name\" value=\"\" size=\"60\" maxlength=\"128\" class=\"form-text form-input\" \/>\n\n        <\/div>\n<div class=\"focused-label js-form-item form-item js-form-type-textfield form-item__email js-form-item-email\">\n      <label for=\"edit-email\" class=\"form-label\">Enter 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form-input\" data-drupal-selector=\"edit-resend-otp\" type=\"submit\" id=\"edit-resend-otp\" name=\"op\" value=\"Resend OTP\" \/>\n<\/div>\n<div class=\"terms-field js-form-item form-item js-form-type-checkbox form-item__terms js-form-item-terms\">\n        <input data-drupal-selector=\"edit-terms\" type=\"checkbox\" id=\"edit-terms\" name=\"terms\" value=\"1\" checked=\"checked\" class=\"form-checkbox form-input\" \/>\n\n        <label for=\"edit-terms\" class=\"form-label option\">I Agree <a class=\"edit-button use-ajax\"\n      data-dialog-options=\"{&quot;width&quot;:400}\"\n      data-dialog-type=\"dialog\"\n      href=\"\/terms\"\">To The Terms & Conditions<\/a>.<\/label>\n      <\/div>\n<div class=\"js-form-item form-item js-form-type-textfield form-item__docid js-form-item-docid\">\n      <label for=\"edit-docid\" class=\"form-label\">Docid<\/label>\n        <input id=\"docid-form-container\" data-drupal-selector=\"edit-docid\" type=\"text\" name=\"docid\" value=\"\" size=\"60\" maxlength=\"128\" class=\"form-text form-input\" \/>\n\n        <\/div>\n<div class=\"js-form-item form-item js-form-type-textfield form-item__specialityid js-form-item-specialityid\">\n      <label for=\"edit-specialityid\" class=\"form-label\">Specid<\/label>\n        <input id=\"specid-form-container\" data-drupal-selector=\"edit-specialityid\" type=\"text\" name=\"specialityid\" value=\"\" size=\"60\" maxlength=\"128\" class=\"form-text form-input\" \/>\n\n        <\/div>\n<input class=\"close-button button js-form-submit form-submit form-input\" data-drupal-selector=\"edit-close\" type=\"submit\" id=\"edit-close\" name=\"op\" value=\"Close\" \/>\n<input class=\"submit-button button js-form-submit form-submit form-input\" data-drupal-selector=\"edit-verify\" type=\"submit\" id=\"edit-verify\" name=\"op\" value=\"Submit\" \/>\n<\/div>\n<\/div>\n<input autocomplete=\"off\" data-drupal-selector=\"form-l6zzcnuuqio38mkd98mnpd9y9xcpihrmcuskk98ada4\" type=\"hidden\" 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