{"id":559,"date":"2025-01-03T09:36:47","date_gmt":"2025-01-03T09:36:47","guid":{"rendered":"https:\/\/portal.takaful.lk\/callback-request\/?page_id=559"},"modified":"2025-01-03T11:38:09","modified_gmt":"2025-01-03T11:38:09","slug":"medical-esu-intimation","status":"publish","type":"page","link":"https:\/\/portal.takaful.lk\/callback-request\/medical-esu-intimation\/","title":{"rendered":"MEDICAL ESU INTIMATION"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"559\" class=\"elementor elementor-559\">\n\t\t\t\t<div class=\"elementor-element elementor-element-580568a e-flex e-con-boxed elementor-invisible e-con e-parent\" data-id=\"580568a\" data-element_type=\"container\" data-settings=\"{&quot;animation&quot;:&quot;fadeInUp&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-bfa319e elementor-view-default elementor-position-top elementor-mobile-position-top elementor-widget elementor-widget-icon-box\" data-id=\"bfa319e\" data-element_type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon elementor-animation-sink\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fab-wpforms\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M448 75.2v361.7c0 24.3-19 43.2-43.2 43.2H43.2C19.3 480 0 461.4 0 436.8V75.2C0 51.1 18.8 32 43.2 32h361.7c24 0 43.1 18.8 43.1 43.2zm-37.3 361.6V75.2c0-3-2.6-5.8-5.8-5.8h-9.3L285.3 144 224 94.1 162.8 144 52.5 69.3h-9.3c-3.2 0-5.8 2.8-5.8 5.8v361.7c0 3 2.6 5.8 5.8 5.8h361.7c3.2.1 5.8-2.7 5.8-5.8zM150.2 186v37H76.7v-37h73.5zm0 74.4v37.3H76.7v-37.3h73.5zm11.1-147.3l54-43.7H96.8l64.5 43.7zm210 72.9v37h-196v-37h196zm0 74.4v37.3h-196v-37.3h196zm-84.6-147.3l64.5-43.7H232.8l53.9 43.7zM371.3 335v37.3h-99.4V335h99.4z\"><\/path><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<span  >\n\t\t\t\t\t\t\tMEDICAL ESU INTIMATION\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tFILL AND SUBMIT THE BELLOW FORM\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\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-ef0d68e e-flex e-con-boxed elementor-invisible e-con e-parent\" data-id=\"ef0d68e\" data-element_type=\"container\" data-settings=\"{&quot;animation&quot;:&quot;fadeInUp&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7f14201 e-n-tabs-mobile elementor-widget elementor-widget-n-tabs\" data-id=\"7f14201\" data-element_type=\"widget\" data-widget_type=\"nested-tabs.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"e-n-tabs\" data-widget-number=\"133251585\" aria-label=\"Tabs. Open items with Enter or Space, close with Escape and navigate using the Arrow keys.\">\n\t\t\t<div class=\"e-n-tabs-heading\" role=\"tablist\">\n\t\t\t\t\t<button id=\"e-n-tab-title-1332515851\" class=\"e-n-tab-title\" aria-selected=\"true\" data-tab-index=\"1\" role=\"tab\" tabindex=\"0\" aria-controls=\"e-n-tab-content-1332515851\" style=\"--n-tabs-title-order: 1;\">\n\t\t\t\t\t\t<span class=\"e-n-tab-title-text\">\n\t\t\t\tMedical New Admission\t\t\t<\/span>\n\t\t<\/button>\n\t\t\t\t<button id=\"e-n-tab-title-1332515852\" class=\"e-n-tab-title\" aria-selected=\"false\" data-tab-index=\"2\" role=\"tab\" tabindex=\"-1\" aria-controls=\"e-n-tab-content-1332515852\" style=\"--n-tabs-title-order: 2;\">\n\t\t\t\t\t\t<span class=\"e-n-tab-title-text\">\n\t\t\t\tMedical Hospital Discharge\t\t\t<\/span>\n\t\t<\/button>\n\t\t\t\t\t<\/div>\n\t\t\t<div class=\"e-n-tabs-content\">\n\t\t\t\t<div id=\"e-n-tab-content-1332515851\" role=\"tabpanel\" aria-labelledby=\"e-n-tab-title-1332515851\" data-tab-index=\"1\" style=\"--n-tabs-title-order: 1;\" class=\"e-active elementor-element elementor-element-2c66c94 e-flex e-con-boxed e-con e-child\" data-id=\"2c66c94\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-7ccbca7 e-con-full e-flex e-con e-child\" data-id=\"7ccbca7\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b3f9e95 elementor-widget elementor-widget-shortcode\" data-id=\"b3f9e95\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-561 forminator-design--flat  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-561\" data-uid=\"69ddd8b9b54cd\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-561\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-561 forminator-design--flat  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"561\"\n\t\t\t\t\n\t\t\t\tdata-design=\"flat\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"open\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t\t\n\t\t\t\tdata-uid=\"69ddd8b9b54cd\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69ddd8b9b54cd\" id=\"forminator-field-name-1_69ddd8b9b54cd-label\" class=\"forminator-label\">Patient\u2019s Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-1_69ddd8b9b54cd\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69ddd8b9b54cd\" id=\"forminator-field-phone-1_69ddd8b9b54cd-label\" class=\"forminator-label\">Contact Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69ddd8b9b54cd\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69ddd8b9b54cd\" id=\"forminator-field-text-1_69ddd8b9b54cd-label\" class=\"forminator-label\">Policy Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69ddd8b9b54cd\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69ddd8b9b54cd\" id=\"forminator-field-text-2_69ddd8b9b54cd-label\" class=\"forminator-label\">Nic Number of the Primary Member (Policy Holders) <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69ddd8b9b54cd\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69ddd8b9b54cd\" id=\"forminator-field-text-3_69ddd8b9b54cd-label\" class=\"forminator-label\">Company Name<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_69ddd8b9b54cd\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_69ddd8b9b54cd\" id=\"forminator-field-text-4_69ddd8b9b54cd-label\" class=\"forminator-label\">Hospital Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_69ddd8b9b54cd\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-1\" class=\"forminator-field-number forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-1_69ddd8b9b54cd\" id=\"forminator-field-number-1_69ddd8b9b54cd-label\" class=\"forminator-label\">Room Number <span class=\"forminator-required\">*<\/span><\/label><input name=\"number-1\" value=\"\" placeholder=\"\" id=\"forminator-field-number-1_69ddd8b9b54cd\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"1\" data-decimals=\"0\" aria-required=\"true\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"150\" \/><\/div><\/div><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_69ddd8b9b54cd\" id=\"forminator-field-textarea-1_69ddd8b9b54cd-label\" class=\"forminator-label\">Reason for Admission <span class=\"forminator-required\">*<\/span><\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_69ddd8b9b54cd\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69ddd8b9b54cd\" id=\"forminator-field-date-1-picker_69ddd8b9b54cd-label\" class=\"forminator-label\">Admission Date <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-1-picker_69ddd8b9b54cd\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_69ddd8b9b54cd\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"time-1\" class=\"forminator-field-time forminator-col forminator-col-6 \"><label for=\"forminator-field-time-1\" id=\"forminator-field-time-1-label\" class=\"forminator-label\">Admission Time <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-timepicker\" ><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"time-1-hours\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-time-1-hours_69ddd8b9b54cd\" id=\"forminator-field-time-1-hours_69ddd8b9b54cd-label\" class=\"forminator-label\">Hours<\/label><input type=\"number\" name=\"time-1-hours\" min=\"0\" max=\"12\" placeholder=\"E.g. 08\" id=\"forminator-field-time-1-hours_69ddd8b9b54cd\" class=\"forminator-input time-hours \" data-field=\"hours\" value=\"\" \/><\/div><\/div><div id=\"time-1-minutes\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-time-1-minutes_69ddd8b9b54cd\" id=\"forminator-field-time-1-minutes_69ddd8b9b54cd-label\" class=\"forminator-label\">Minutes<\/label><input type=\"number\" min=\"0\" max=\"59\" name=\"time-1-minutes\" placeholder=\"E.g. 00\" id=\"forminator-field-time-1-minutes_69ddd8b9b54cd\" class=\"forminator-input time-minutes \" data-field=\"minutes\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><select name=\"time-1-ampm\" id=\"forminator-field-561__field--time-1-ampm_69ddd8b9b54cd\" class=\"forminator-select2 time-ampm \" data-field=\"ampm\" data-default-value=\"\"><option value=\"am\" >AM<\/option><option value=\"pm\" >PM<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_69ddd8b9b54cd\" id=\"forminator-field-date-2-picker_69ddd8b9b54cd-label\" class=\"forminator-label\">Intimation Date <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-2-picker_69ddd8b9b54cd\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-2-picker_69ddd8b9b54cd\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"time-2\" class=\"forminator-field-time forminator-col forminator-col-6 \"><label for=\"forminator-field-time-2\" id=\"forminator-field-time-2-label\" class=\"forminator-label\">Intimation Time: <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-timepicker\" ><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"time-2-hours\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-time-2-hours_69ddd8b9b54cd\" id=\"forminator-field-time-2-hours_69ddd8b9b54cd-label\" class=\"forminator-label\">Hours<\/label><input type=\"number\" name=\"time-2-hours\" min=\"0\" max=\"12\" placeholder=\"E.g. 08\" id=\"forminator-field-time-2-hours_69ddd8b9b54cd\" class=\"forminator-input time-hours \" data-field=\"hours\" value=\"\" \/><\/div><\/div><div id=\"time-2-minutes\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-time-2-minutes_69ddd8b9b54cd\" id=\"forminator-field-time-2-minutes_69ddd8b9b54cd-label\" class=\"forminator-label\">Minutes<\/label><input type=\"number\" min=\"0\" max=\"59\" name=\"time-2-minutes\" placeholder=\"E.g. 00\" id=\"forminator-field-time-2-minutes_69ddd8b9b54cd\" class=\"forminator-input time-minutes \" data-field=\"minutes\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><select name=\"time-2-ampm\" id=\"forminator-field-561__field--time-2-ampm_69ddd8b9b54cd\" class=\"forminator-select2 time-ampm \" data-field=\"ampm\" data-default-value=\"\"><option value=\"am\" >AM<\/option><option value=\"pm\" >PM<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69ddd8b9b54cd\" id=\"forminator-field-text-5_69ddd8b9b54cd-label\" class=\"forminator-label\">Intimated by <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_69ddd8b9b54cd\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"f825d7e76c\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/callback-request\/wp-json\/wp\/v2\/pages\/559\" \/><input type=\"hidden\" name=\"form_id\" value=\"561\"><input type=\"hidden\" name=\"page_id\" value=\"559\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/portal.takaful.lk\/callback-request\/medical-esu-intimation\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/div>\n\t\t\t\t<\/div>\n\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 id=\"e-n-tab-content-1332515852\" role=\"tabpanel\" aria-labelledby=\"e-n-tab-title-1332515852\" data-tab-index=\"2\" style=\"--n-tabs-title-order: 2;\" class=\" elementor-element elementor-element-780e3fa e-flex e-con-boxed e-con e-child\" data-id=\"780e3fa\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-2cdb193 e-con-full e-flex e-con e-child\" data-id=\"2cdb193\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-45d8f61 elementor-widget elementor-widget-shortcode\" data-id=\"45d8f61\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-562 forminator-design--flat  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-562\" data-uid=\"69ddd8b9bc3f4\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-562\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-562 forminator-design--flat  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"562\"\n\t\t\t\t\n\t\t\t\tdata-design=\"flat\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"open\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t\t\n\t\t\t\tdata-uid=\"69ddd8b9bc3f4\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69ddd8b9bc3f4\" id=\"forminator-field-name-1_69ddd8b9bc3f4-label\" class=\"forminator-label\">Patient\u2019s Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-1_69ddd8b9bc3f4\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69ddd8b9bc3f4\" id=\"forminator-field-phone-1_69ddd8b9bc3f4-label\" class=\"forminator-label\">Contact Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69ddd8b9bc3f4\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69ddd8b9bc3f4\" id=\"forminator-field-text-3_69ddd8b9bc3f4-label\" class=\"forminator-label\">Company Name<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_69ddd8b9bc3f4\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_69ddd8b9bc3f4\" id=\"forminator-field-text-4_69ddd8b9bc3f4-label\" class=\"forminator-label\">Hospital Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_69ddd8b9bc3f4\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-1\" class=\"forminator-field-number forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-1_69ddd8b9bc3f4\" id=\"forminator-field-number-1_69ddd8b9bc3f4-label\" class=\"forminator-label\">Room Number <span class=\"forminator-required\">*<\/span><\/label><input name=\"number-1\" value=\"\" placeholder=\"\" id=\"forminator-field-number-1_69ddd8b9bc3f4\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"1\" data-decimals=\"0\" aria-required=\"true\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"150\" \/><\/div><\/div><div id=\"time-1\" class=\"forminator-field-time forminator-col forminator-col-6 \"><label for=\"forminator-field-time-1\" id=\"forminator-field-time-1-label\" class=\"forminator-label\">If Client Informed At the Time of Admission <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-timepicker\" ><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"time-1-hours\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-time-1-hours_69ddd8b9bc3f4\" id=\"forminator-field-time-1-hours_69ddd8b9bc3f4-label\" class=\"forminator-label\">Hours<\/label><input type=\"number\" name=\"time-1-hours\" min=\"0\" max=\"12\" placeholder=\"E.g. 08\" id=\"forminator-field-time-1-hours_69ddd8b9bc3f4\" class=\"forminator-input time-hours \" data-field=\"hours\" value=\"\" \/><\/div><\/div><div id=\"time-1-minutes\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-time-1-minutes_69ddd8b9bc3f4\" id=\"forminator-field-time-1-minutes_69ddd8b9bc3f4-label\" class=\"forminator-label\">Minutes<\/label><input type=\"number\" min=\"0\" max=\"59\" name=\"time-1-minutes\" placeholder=\"E.g. 00\" id=\"forminator-field-time-1-minutes_69ddd8b9bc3f4\" class=\"forminator-input time-minutes \" data-field=\"minutes\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><select name=\"time-1-ampm\" id=\"forminator-field-562__field--time-1-ampm_69ddd8b9bc3f4\" class=\"forminator-select2 time-ampm \" data-field=\"ampm\" data-default-value=\"\"><option value=\"am\" >AM<\/option><option value=\"pm\" >PM<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_69ddd8b9bc3f4\" id=\"forminator-field-date-2-picker_69ddd8b9bc3f4-label\" class=\"forminator-label\">Intimation Date <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-2-picker_69ddd8b9bc3f4\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-2-picker_69ddd8b9bc3f4\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"time-2\" class=\"forminator-field-time forminator-col forminator-col-6 \"><label for=\"forminator-field-time-2\" id=\"forminator-field-time-2-label\" class=\"forminator-label\">Intimation Time: <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-timepicker\" ><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"time-2-hours\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-time-2-hours_69ddd8b9bc3f4\" id=\"forminator-field-time-2-hours_69ddd8b9bc3f4-label\" class=\"forminator-label\">Hours<\/label><input type=\"number\" name=\"time-2-hours\" min=\"0\" max=\"12\" placeholder=\"E.g. 08\" id=\"forminator-field-time-2-hours_69ddd8b9bc3f4\" class=\"forminator-input time-hours \" data-field=\"hours\" value=\"\" \/><\/div><\/div><div id=\"time-2-minutes\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-time-2-minutes_69ddd8b9bc3f4\" id=\"forminator-field-time-2-minutes_69ddd8b9bc3f4-label\" class=\"forminator-label\">Minutes<\/label><input type=\"number\" min=\"0\" max=\"59\" name=\"time-2-minutes\" placeholder=\"E.g. 00\" id=\"forminator-field-time-2-minutes_69ddd8b9bc3f4\" class=\"forminator-input time-minutes \" data-field=\"minutes\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><select name=\"time-2-ampm\" id=\"forminator-field-562__field--time-2-ampm_69ddd8b9bc3f4\" class=\"forminator-select2 time-ampm \" data-field=\"ampm\" data-default-value=\"\"><option value=\"am\" >AM<\/option><option value=\"pm\" >PM<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69ddd8b9bc3f4-label\"><span id=\"forminator-radiogroup-69ddd8b9bc3f4-label\" class=\"forminator-label\">Final Bills Ready <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-69ddd8b9bc3f4\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-69ddd8b9bc3f4\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-69ddd8b9bc3f4\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-69ddd8b9bc3f4\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69ddd8b9bc3f4\" id=\"forminator-field-text-6_69ddd8b9bc3f4-label\" class=\"forminator-label\">Bill Amount <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_69ddd8b9bc3f4\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69ddd8b9bc3f4\" id=\"forminator-field-text-5_69ddd8b9bc3f4-label\" class=\"forminator-label\">Intimated by <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_69ddd8b9bc3f4\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"7341d6d4e0\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/callback-request\/wp-json\/wp\/v2\/pages\/559\" \/><input type=\"hidden\" name=\"form_id\" value=\"562\"><input type=\"hidden\" name=\"page_id\" value=\"559\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/portal.takaful.lk\/callback-request\/medical-esu-intimation\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/div>\n\t\t\t\t<\/div>\n\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\t\t\t<\/div>\n\t\t<\/div>\n\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\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>MEDICAL ESU INTIMATION FILL AND SUBMIT THE BELLOW FORM Medical New Admission Medical Hospital Discharge<\/p>\n","protected":false},"author":1,"featured_media":534,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-559","page","type-page","status-publish","has-post-thumbnail","hentry"],"_links":{"self":[{"href":"https:\/\/portal.takaful.lk\/callback-request\/wp-json\/wp\/v2\/pages\/559","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/portal.takaful.lk\/callback-request\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/portal.takaful.lk\/callback-request\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/portal.takaful.lk\/callback-request\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/portal.takaful.lk\/callback-request\/wp-json\/wp\/v2\/comments?post=559"}],"version-history":[{"count":7,"href":"https:\/\/portal.takaful.lk\/callback-request\/wp-json\/wp\/v2\/pages\/559\/revisions"}],"predecessor-version":[{"id":618,"href":"https:\/\/portal.takaful.lk\/callback-request\/wp-json\/wp\/v2\/pages\/559\/revisions\/618"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/portal.takaful.lk\/callback-request\/wp-json\/wp\/v2\/media\/534"}],"wp:attachment":[{"href":"https:\/\/portal.takaful.lk\/callback-request\/wp-json\/wp\/v2\/media?parent=559"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}