{"id":13524,"date":"2025-09-19T20:11:05","date_gmt":"2025-09-19T14:41:05","guid":{"rendered":"https:\/\/translumina.com\/in\/?page_id=13524"},"modified":"2025-11-14T12:16:36","modified_gmt":"2025-11-14T06:46:36","slug":"product-evaluation-and-feedback-form-des","status":"publish","type":"page","link":"https:\/\/translumina.com\/in\/product-evaluation-and-feedback-form-des\/","title":{"rendered":"Product evaluation and Feedback form (DES)"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"13524\" class=\"elementor elementor-13524\" data-elementor-post-type=\"page\">\n\t\t\t\t<div data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-element elementor-element-7f96bbf e-flex e-con-boxed elementor-invisible e-con e-parent\" data-id=\"7f96bbf\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;shape_divider_bottom&quot;:&quot;curve&quot;,&quot;shape_divider_bottom_negative&quot;:&quot;yes&quot;,&quot;animation&quot;:&quot;fadeIn&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-shape elementor-shape-bottom\" aria-hidden=\"true\" data-negative=\"true\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 1000 100\" preserveAspectRatio=\"none\">\n\t<path class=\"elementor-shape-fill\" d=\"M500,97C126.7,96.3,0.8,19.8,0,0v100l1000,0V1C1000,19.4,873.3,97.8,500,97z\"\/>\n<\/svg>\t\t<\/div>\n\t\t<div data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-element elementor-element-3584520 e-con-full e-flex elementor-invisible e-con e-child\" data-id=\"3584520\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;animation&quot;:&quot;fadeInUp&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-fc9dc36 line-container line-container-small elementor-hidden-mobile elementor-widget elementor-widget-html\" data-id=\"fc9dc36\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"line\"><\/div>\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 data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-element elementor-element-d29987b e-flex e-con-boxed elementor-invisible e-con e-parent\" data-id=\"d29987b\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;shape_divider_bottom&quot;:&quot;curve&quot;,&quot;shape_divider_bottom_negative&quot;:&quot;yes&quot;,&quot;background_motion_fx_motion_fx_scrolling&quot;:&quot;yes&quot;,&quot;background_motion_fx_scale_effect&quot;:&quot;yes&quot;,&quot;animation&quot;:&quot;fadeInUp&quot;,&quot;background_motion_fx_scale_direction&quot;:&quot;out-in&quot;,&quot;background_motion_fx_scale_speed&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:4,&quot;sizes&quot;:[]},&quot;background_motion_fx_scale_range&quot;:{&quot;unit&quot;:&quot;%&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:{&quot;start&quot;:20,&quot;end&quot;:80}},&quot;background_motion_fx_devices&quot;:[&quot;widescreen&quot;,&quot;desktop&quot;,&quot;laptop&quot;,&quot;tablet_extra&quot;,&quot;tablet&quot;,&quot;mobile_extra&quot;,&quot;mobile&quot;]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-shape elementor-shape-bottom\" aria-hidden=\"true\" data-negative=\"true\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 1000 100\" preserveAspectRatio=\"none\">\n\t<path class=\"elementor-shape-fill\" d=\"M500,97C126.7,96.3,0.8,19.8,0,0v100l1000,0V1C1000,19.4,873.3,97.8,500,97z\"\/>\n<\/svg>\t\t<\/div>\n\t\t<div data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-element elementor-element-bbb26da e-con-full form-evalution e-flex e-con e-child\" data-id=\"bbb26da\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-db44096 elementor-widget__width-inherit elementor-widget-mobile__width-inherit elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"db44096\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;step_type&quot;:&quot;none&quot;,&quot;step_icon_shape&quot;:&quot;none&quot;,&quot;button_width&quot;:&quot;100&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"DES\" aria-label=\"DES\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"13524\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"db44096\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-productname elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-productname\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tProduct Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[productname]\" id=\"form-field-productname\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-batchno elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-batchno\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLot\/Batch No.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[batchno]\" id=\"form-field-batchno\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-serialno elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-serialno\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSerial No.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[serialno]\" id=\"form-field-serialno\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-balloonsize elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-balloonsize\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStent Size   (Diameter  & Length) mm  \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[balloonsize]\" id=\"form-field-balloonsize\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-qty elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-qty\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tQty.:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[qty]\" id=\"form-field-qty\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_d2764e2 elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-hospitalname elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hospitalname\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHospital Name & Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[hospitalname]\" id=\"form-field-hospitalname\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-physicianname elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-physicianname\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInterventional Cardiologist\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[physicianname]\" id=\"form-field-physicianname\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-dateprocedure elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dateprocedure\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of Procedure\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[dateprocedure]\" id=\"form-field-dateprocedure\" class=\"elementor-field elementor-size-xs  elementor-field-textual elementor-date-field\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-telephone elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-telephone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTelephone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[telephone]\" id=\"form-field-telephone\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-email elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmail\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" placeholder=\"Email\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_e159b44 elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_a0a3a35 elementor-col-100\">\n\t\t\t\t\tPatient Information: \t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-age elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-age\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAge:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[age]\" id=\"form-field-age\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-sex elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-sex\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSex:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Male\" id=\"form-field-sex-0\" name=\"form_fields[sex]\" required=\"required\"> <label for=\"form-field-sex-0\">Male<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Female\" id=\"form-field-sex-1\" name=\"form_fields[sex]\" required=\"required\"> <label for=\"form-field-sex-1\">Female<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_825b166 elementor-col-100\">\n\t\t\t\t\tPlease tick anatomical location of the stenosis:\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-rightcoronary elementor-col-20\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"1. RCA proximal \" id=\"form-field-rightcoronary-0\" name=\"form_fields[rightcoronary][]\"> <label for=\"form-field-rightcoronary-0\">1. RCA proximal <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"2. RCA mid \" id=\"form-field-rightcoronary-1\" name=\"form_fields[rightcoronary][]\"> <label for=\"form-field-rightcoronary-1\">2. RCA mid <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"3. RCA distal\" id=\"form-field-rightcoronary-2\" name=\"form_fields[rightcoronary][]\"> <label for=\"form-field-rightcoronary-2\">3. RCA distal<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"4. Right posterior descendens\" id=\"form-field-rightcoronary-3\" name=\"form_fields[rightcoronary][]\"> <label for=\"form-field-rightcoronary-3\">4. Right posterior descendens<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"5. Main stem \" id=\"form-field-rightcoronary-4\" name=\"form_fields[rightcoronary][]\"> <label for=\"form-field-rightcoronary-4\">5. Main stem <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"6. LAD proximal \" id=\"form-field-rightcoronary-5\" name=\"form_fields[rightcoronary][]\"> <label for=\"form-field-rightcoronary-5\">6. LAD proximal <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"7. LAD mid \" id=\"form-field-rightcoronary-6\" name=\"form_fields[rightcoronary][]\"> <label for=\"form-field-rightcoronary-6\">7. LAD mid <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"8. LAD distal \" id=\"form-field-rightcoronary-7\" name=\"form_fields[rightcoronary][]\"> <label for=\"form-field-rightcoronary-7\">8. LAD distal <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_c3ccdc4 elementor-col-40\">\n\t\t\t\t\t<div style=\"text-align:center;font-size: 0.9rem; font-weight: 500;color: var(--e-global-color-e949215);\"><label for=\"form-field-field_054d205\" class=\"elementor-field-label\">Vessel \/ Position of Stenosis\t\t\t\t\t<\/label><br><img decoding=\"async\" src=\"https:\/\/translumina.com\/in\/wp-content\/uploads\/2025\/09\/rca-lca.png\" border=\"0\"  style=\"width:300px\"><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-leftcoronary5afff elementor-col-33\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"9. First Digonal\" id=\"form-field-leftcoronary5afff-0\" name=\"form_fields[leftcoronary5afff][]\"> <label for=\"form-field-leftcoronary5afff-0\">9. First Digonal<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"10. Second digonal \" id=\"form-field-leftcoronary5afff-1\" name=\"form_fields[leftcoronary5afff][]\"> <label for=\"form-field-leftcoronary5afff-1\">10. Second digonal <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"11. Cricumflex proximal \" id=\"form-field-leftcoronary5afff-2\" name=\"form_fields[leftcoronary5afff][]\"> <label for=\"form-field-leftcoronary5afff-2\">11. Cricumflex proximal <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"12. Obtuse margina\" id=\"form-field-leftcoronary5afff-3\" name=\"form_fields[leftcoronary5afff][]\"> <label for=\"form-field-leftcoronary5afff-3\">12. Obtuse margina<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"13. Circumflex Distal \" id=\"form-field-leftcoronary5afff-4\" name=\"form_fields[leftcoronary5afff][]\"> <label for=\"form-field-leftcoronary5afff-4\">13. Circumflex Distal <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"14. Postero-lateral from LCX\" id=\"form-field-leftcoronary5afff-5\" name=\"form_fields[leftcoronary5afff][]\"> <label for=\"form-field-leftcoronary5afff-5\">14. Postero-lateral from LCX<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"15. Postero -descendens from LCX\" id=\"form-field-leftcoronary5afff-6\" name=\"form_fields[leftcoronary5afff][]\"> <label for=\"form-field-leftcoronary5afff-6\">15. Postero -descendens from LCX<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"16. Postero-lateral from RCA\" id=\"form-field-leftcoronary5afff-7\" name=\"form_fields[leftcoronary5afff][]\"> <label for=\"form-field-leftcoronary5afff-7\">16. Postero-lateral from RCA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_57d8a3f elementor-col-100\">\n\t\t\t\t\tPlease indicate lesion characteristics:\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-lesiontype elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-lesiontype\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLesion Type (Please Tick):\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"A\" id=\"form-field-lesiontype-0\" name=\"form_fields[lesiontype][]\"> <label for=\"form-field-lesiontype-0\">A<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"B1\" id=\"form-field-lesiontype-1\" name=\"form_fields[lesiontype][]\"> <label for=\"form-field-lesiontype-1\">B1<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"B2\" id=\"form-field-lesiontype-2\" name=\"form_fields[lesiontype][]\"> <label for=\"form-field-lesiontype-2\">B2<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"C\" id=\"form-field-lesiontype-3\" name=\"form_fields[lesiontype][]\"> <label for=\"form-field-lesiontype-3\">C<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_f79a94b elementor-col-100\">\n\t\t\t\t\tLesion Morphology:\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-concentric elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-concentric\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLesion Type: \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Eccentric \" id=\"form-field-concentric-0\" name=\"form_fields[concentric][]\"> <label for=\"form-field-concentric-0\">Eccentric <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Concentric \" id=\"form-field-concentric-1\" name=\"form_fields[concentric][]\"> <label for=\"form-field-concentric-1\">Concentric <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Diffuse \" id=\"form-field-concentric-2\" name=\"form_fields[concentric][]\"> <label for=\"form-field-concentric-2\">Diffuse <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Focal \" id=\"form-field-concentric-3\" name=\"form_fields[concentric][]\"> <label for=\"form-field-concentric-3\">Focal <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Others\" id=\"form-field-concentric-4\" name=\"form_fields[concentric][]\"> <label for=\"form-field-concentric-4\">Others<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_9a4a6d2 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9a4a6d2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLesion calcification:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Severe \" id=\"form-field-field_9a4a6d2-0\" name=\"form_fields[field_9a4a6d2][]\"> <label for=\"form-field-field_9a4a6d2-0\">Severe <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Moderate \" id=\"form-field-field_9a4a6d2-1\" name=\"form_fields[field_9a4a6d2][]\"> <label for=\"form-field-field_9a4a6d2-1\">Moderate <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Little\/none \" id=\"form-field-field_9a4a6d2-2\" name=\"form_fields[field_9a4a6d2][]\"> <label for=\"form-field-field_9a4a6d2-2\">Little\/none <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Unknown \" id=\"form-field-field_9a4a6d2-3\" name=\"form_fields[field_9a4a6d2][]\"> <label for=\"form-field-field_9a4a6d2-3\">Unknown <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_da36eac elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_da36eac\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tVessel angulation: \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"&lt;45\u00b0 \" id=\"form-field-field_da36eac-0\" name=\"form_fields[field_da36eac][]\"> <label for=\"form-field-field_da36eac-0\"><45\u00b0 <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"45\u00b0-90\u00b0 \" id=\"form-field-field_da36eac-1\" name=\"form_fields[field_da36eac][]\"> <label for=\"form-field-field_da36eac-1\">45\u00b0-90\u00b0 <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"&gt; 90\u00b0\" id=\"form-field-field_da36eac-2\" name=\"form_fields[field_da36eac][]\"> <label for=\"form-field-field_da36eac-2\">> 90\u00b0<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_b5e04de elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b5e04de\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tType of stent thrombosis: \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Acute \" id=\"form-field-field_b5e04de-0\" name=\"form_fields[field_b5e04de][]\"> <label for=\"form-field-field_b5e04de-0\">Acute <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Sub-acute \" id=\"form-field-field_b5e04de-1\" name=\"form_fields[field_b5e04de][]\"> <label for=\"form-field-field_b5e04de-1\">Sub-acute <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Late \" id=\"form-field-field_b5e04de-2\" name=\"form_fields[field_b5e04de][]\"> <label for=\"form-field-field_b5e04de-2\">Late <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Very late \" id=\"form-field-field_b5e04de-3\" name=\"form_fields[field_b5e04de][]\"> <label for=\"form-field-field_b5e04de-3\">Very late <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5a4d10b elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5a4d10b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTarget vessel stenosis:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5a4d10b]\" id=\"form-field-field_5a4d10b\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" placeholder=\"%\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_0d3c78a elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0d3c78a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tChronic total occlusion:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_0d3c78a-0\" name=\"form_fields[field_0d3c78a][]\"> <label for=\"form-field-field_0d3c78a-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_0d3c78a-1\" name=\"form_fields[field_0d3c78a][]\"> <label for=\"form-field-field_0d3c78a-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_741d713 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_741d713\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIn stent Restenosis lesion: \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_741d713-0\" name=\"form_fields[field_741d713][]\"> <label for=\"form-field-field_741d713-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_741d713-1\" name=\"form_fields[field_741d713][]\"> <label for=\"form-field-field_741d713-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_f3abfb9 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f3abfb9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOstial or Bifurcation lesion:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_f3abfb9-0\" name=\"form_fields[field_f3abfb9][]\"> <label for=\"form-field-field_f3abfb9-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_f3abfb9-1\" name=\"form_fields[field_f3abfb9][]\"> <label for=\"form-field-field_f3abfb9-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d75d5e8 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d75d5e8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tComparison with routinely used competitor DES: \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d75d5e8]\" id=\"form-field-field_d75d5e8\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_cfcb911 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cfcb911\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease rate your perception of the clinical challenge of this procedure\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Extremely Challenging\" id=\"form-field-field_cfcb911-0\" name=\"form_fields[field_cfcb911]\"> <label for=\"form-field-field_cfcb911-0\">Extremely Challenging<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Moderately Challenging\" id=\"form-field-field_cfcb911-1\" name=\"form_fields[field_cfcb911]\"> <label for=\"form-field-field_cfcb911-1\">Moderately Challenging<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Not Challenging\" id=\"form-field-field_cfcb911-2\" name=\"form_fields[field_cfcb911]\"> <label for=\"form-field-field_cfcb911-2\">Not Challenging<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_cf15453 elementor-col-100\">\n\t\t\t\t\tPlease rate the product performances:\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_a3dffb0 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a3dffb0\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDeliverability\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Excellent\" id=\"form-field-field_a3dffb0-0\" name=\"form_fields[field_a3dffb0]\"> <label for=\"form-field-field_a3dffb0-0\">Excellent<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Good\" id=\"form-field-field_a3dffb0-1\" name=\"form_fields[field_a3dffb0]\"> <label for=\"form-field-field_a3dffb0-1\">Good<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Satisfactory\" id=\"form-field-field_a3dffb0-2\" name=\"form_fields[field_a3dffb0]\"> <label for=\"form-field-field_a3dffb0-2\">Satisfactory<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Fair\" id=\"form-field-field_a3dffb0-3\" name=\"form_fields[field_a3dffb0]\"> <label for=\"form-field-field_a3dffb0-3\">Fair<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Poor \" id=\"form-field-field_a3dffb0-4\" name=\"form_fields[field_a3dffb0]\"> <label for=\"form-field-field_a3dffb0-4\">Poor <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_6491056 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6491056\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStent Visibility\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Excellent\" id=\"form-field-field_6491056-0\" name=\"form_fields[field_6491056]\"> <label for=\"form-field-field_6491056-0\">Excellent<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Good\" id=\"form-field-field_6491056-1\" name=\"form_fields[field_6491056]\"> <label for=\"form-field-field_6491056-1\">Good<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Satisfactory\" id=\"form-field-field_6491056-2\" name=\"form_fields[field_6491056]\"> <label for=\"form-field-field_6491056-2\">Satisfactory<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Fair\" id=\"form-field-field_6491056-3\" name=\"form_fields[field_6491056]\"> <label for=\"form-field-field_6491056-3\">Fair<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Poor \" id=\"form-field-field_6491056-4\" name=\"form_fields[field_6491056]\"> <label for=\"form-field-field_6491056-4\">Poor <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_98c505c elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_98c505c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFlexibility\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Excellent\" id=\"form-field-field_98c505c-0\" name=\"form_fields[field_98c505c]\"> <label for=\"form-field-field_98c505c-0\">Excellent<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Good\" id=\"form-field-field_98c505c-1\" name=\"form_fields[field_98c505c]\"> <label for=\"form-field-field_98c505c-1\">Good<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Satisfactory\" id=\"form-field-field_98c505c-2\" name=\"form_fields[field_98c505c]\"> <label for=\"form-field-field_98c505c-2\">Satisfactory<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Fair\" id=\"form-field-field_98c505c-3\" name=\"form_fields[field_98c505c]\"> <label for=\"form-field-field_98c505c-3\">Fair<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Poor \" id=\"form-field-field_98c505c-4\" name=\"form_fields[field_98c505c]\"> <label for=\"form-field-field_98c505c-4\">Poor <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_9652bad elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9652bad\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStent Shortening\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Excellent\" id=\"form-field-field_9652bad-0\" name=\"form_fields[field_9652bad]\"> <label for=\"form-field-field_9652bad-0\">Excellent<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Good\" id=\"form-field-field_9652bad-1\" name=\"form_fields[field_9652bad]\"> <label for=\"form-field-field_9652bad-1\">Good<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Satisfactory\" id=\"form-field-field_9652bad-2\" name=\"form_fields[field_9652bad]\"> <label for=\"form-field-field_9652bad-2\">Satisfactory<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Fair\" id=\"form-field-field_9652bad-3\" name=\"form_fields[field_9652bad]\"> <label for=\"form-field-field_9652bad-3\">Fair<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Poor \" id=\"form-field-field_9652bad-4\" name=\"form_fields[field_9652bad]\"> <label for=\"form-field-field_9652bad-4\">Poor <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_fa5ddfe elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fa5ddfe\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCrossability\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Excellent\" id=\"form-field-field_fa5ddfe-0\" name=\"form_fields[field_fa5ddfe]\"> <label for=\"form-field-field_fa5ddfe-0\">Excellent<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Good\" id=\"form-field-field_fa5ddfe-1\" name=\"form_fields[field_fa5ddfe]\"> <label for=\"form-field-field_fa5ddfe-1\">Good<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Satisfactory\" id=\"form-field-field_fa5ddfe-2\" name=\"form_fields[field_fa5ddfe]\"> <label for=\"form-field-field_fa5ddfe-2\">Satisfactory<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Fair\" id=\"form-field-field_fa5ddfe-3\" name=\"form_fields[field_fa5ddfe]\"> <label for=\"form-field-field_fa5ddfe-3\">Fair<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Poor \" id=\"form-field-field_fa5ddfe-4\" name=\"form_fields[field_fa5ddfe]\"> <label for=\"form-field-field_fa5ddfe-4\">Poor <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_72e04a3 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_72e04a3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDeflation time \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Excellent\" id=\"form-field-field_72e04a3-0\" name=\"form_fields[field_72e04a3]\"> <label for=\"form-field-field_72e04a3-0\">Excellent<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Good\" id=\"form-field-field_72e04a3-1\" name=\"form_fields[field_72e04a3]\"> <label for=\"form-field-field_72e04a3-1\">Good<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Satisfactory\" id=\"form-field-field_72e04a3-2\" name=\"form_fields[field_72e04a3]\"> <label for=\"form-field-field_72e04a3-2\">Satisfactory<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Fair\" id=\"form-field-field_72e04a3-3\" name=\"form_fields[field_72e04a3]\"> <label for=\"form-field-field_72e04a3-3\">Fair<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Poor \" id=\"form-field-field_72e04a3-4\" name=\"form_fields[field_72e04a3]\"> <label for=\"form-field-field_72e04a3-4\">Poor <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_7402c3f elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7402c3f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tConformability\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Excellent\" id=\"form-field-field_7402c3f-0\" name=\"form_fields[field_7402c3f]\"> <label for=\"form-field-field_7402c3f-0\">Excellent<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Good\" id=\"form-field-field_7402c3f-1\" name=\"form_fields[field_7402c3f]\"> <label for=\"form-field-field_7402c3f-1\">Good<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Satisfactory\" id=\"form-field-field_7402c3f-2\" name=\"form_fields[field_7402c3f]\"> <label for=\"form-field-field_7402c3f-2\">Satisfactory<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Fair\" id=\"form-field-field_7402c3f-3\" name=\"form_fields[field_7402c3f]\"> <label for=\"form-field-field_7402c3f-3\">Fair<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Poor \" id=\"form-field-field_7402c3f-4\" name=\"form_fields[field_7402c3f]\"> <label for=\"form-field-field_7402c3f-4\">Poor <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_dab733b elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dab733b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPre-dilatation Stent \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Excellent\" id=\"form-field-field_dab733b-0\" name=\"form_fields[field_dab733b]\"> <label for=\"form-field-field_dab733b-0\">Excellent<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Good\" id=\"form-field-field_dab733b-1\" name=\"form_fields[field_dab733b]\"> <label for=\"form-field-field_dab733b-1\">Good<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Satisfactory\" id=\"form-field-field_dab733b-2\" name=\"form_fields[field_dab733b]\"> <label for=\"form-field-field_dab733b-2\">Satisfactory<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Fair\" id=\"form-field-field_dab733b-3\" name=\"form_fields[field_dab733b]\"> <label for=\"form-field-field_dab733b-3\">Fair<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Poor \" id=\"form-field-field_dab733b-4\" name=\"form_fields[field_dab733b]\"> <label for=\"form-field-field_dab733b-4\">Poor <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_091e614 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_091e614\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPushability\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Excellent\" id=\"form-field-field_091e614-0\" name=\"form_fields[field_091e614]\"> <label for=\"form-field-field_091e614-0\">Excellent<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Good\" id=\"form-field-field_091e614-1\" name=\"form_fields[field_091e614]\"> <label for=\"form-field-field_091e614-1\">Good<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Satisfactory\" id=\"form-field-field_091e614-2\" name=\"form_fields[field_091e614]\"> <label for=\"form-field-field_091e614-2\">Satisfactory<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Fair\" id=\"form-field-field_091e614-3\" name=\"form_fields[field_091e614]\"> <label for=\"form-field-field_091e614-3\">Fair<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Poor \" id=\"form-field-field_091e614-4\" name=\"form_fields[field_091e614]\"> <label for=\"form-field-field_091e614-4\">Poor <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_ca48c03 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ca48c03\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPost-dilatation Stent \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Excellent\" id=\"form-field-field_ca48c03-0\" name=\"form_fields[field_ca48c03]\"> <label for=\"form-field-field_ca48c03-0\">Excellent<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Good\" id=\"form-field-field_ca48c03-1\" name=\"form_fields[field_ca48c03]\"> <label for=\"form-field-field_ca48c03-1\">Good<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Satisfactory\" id=\"form-field-field_ca48c03-2\" name=\"form_fields[field_ca48c03]\"> <label for=\"form-field-field_ca48c03-2\">Satisfactory<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Fair\" id=\"form-field-field_ca48c03-3\" name=\"form_fields[field_ca48c03]\"> <label for=\"form-field-field_ca48c03-3\">Fair<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Poor \" id=\"form-field-field_ca48c03-4\" name=\"form_fields[field_ca48c03]\"> <label for=\"form-field-field_ca48c03-4\">Poor <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_a6121cc elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a6121cc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInflation time\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Excellent\" id=\"form-field-field_a6121cc-0\" name=\"form_fields[field_a6121cc]\"> <label for=\"form-field-field_a6121cc-0\">Excellent<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Good\" id=\"form-field-field_a6121cc-1\" name=\"form_fields[field_a6121cc]\"> <label for=\"form-field-field_a6121cc-1\">Good<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Satisfactory\" id=\"form-field-field_a6121cc-2\" name=\"form_fields[field_a6121cc]\"> <label for=\"form-field-field_a6121cc-2\">Satisfactory<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Fair\" id=\"form-field-field_a6121cc-3\" name=\"form_fields[field_a6121cc]\"> <label for=\"form-field-field_a6121cc-3\">Fair<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Poor \" id=\"form-field-field_a6121cc-4\" name=\"form_fields[field_a6121cc]\"> <label for=\"form-field-field_a6121cc-4\">Poor <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_5ccdd67 elementor-col-100\">\n\t\t\t\t\tInflation & Deflation Data:\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_80ebc3c elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_80ebc3c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMax. Inflation Pressure \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_80ebc3c]\" id=\"form-field-field_80ebc3c\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" placeholder=\"Bar\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7174c3e elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7174c3e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNumber of Inflation (n):\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7174c3e]\" id=\"form-field-field_7174c3e\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" placeholder=\"Number of Inflation (n)\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_33e57e6 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_33e57e6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tUsed in Multiple lesion?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_33e57e6-0\" name=\"form_fields[field_33e57e6][]\"> <label for=\"form-field-field_33e57e6-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_33e57e6-1\" name=\"form_fields[field_33e57e6][]\"> <label for=\"form-field-field_33e57e6-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d19652b elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d19652b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t Inflation time \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d19652b]\" id=\"form-field-field_d19652b\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" placeholder=\"Sec. \">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_838e83d elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_838e83d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDeflation Time \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_838e83d]\" id=\"form-field-field_838e83d\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" placeholder=\"Sec. \">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_8dae37b elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8dae37b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOverall Performance \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Better \" id=\"form-field-field_8dae37b-0\" name=\"form_fields[field_8dae37b][]\"> <label for=\"form-field-field_8dae37b-0\">Better <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Same \" id=\"form-field-field_8dae37b-1\" name=\"form_fields[field_8dae37b][]\"> <label for=\"form-field-field_8dae37b-1\">Same <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Poor\" id=\"form-field-field_8dae37b-2\" name=\"form_fields[field_8dae37b][]\"> <label for=\"form-field-field_8dae37b-2\">Poor<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_aea1717 elementor-col-66\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_aea1717\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf Overall performance is rated \u201cPoor\u201d, could you please explain the reason:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_aea1717]\" id=\"form-field-field_aea1717\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-adverse elementor-col-66\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-adverse\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAny Adverse Events\/Complications\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[adverse]\" id=\"form-field-adverse\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_759c5dd elementor-col-100\">\n\t\t\t\t\tI further acknowledge the data privacy along with this report:\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_36ad200 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_36ad200\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_36ad200]\" id=\"form-field-field_36ad200\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_fcb5a91 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fcb5a91\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTelephone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_fcb5a91]\" id=\"form-field-field_fcb5a91\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7b0be24 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7b0be24\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmail:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7b0be24]\" id=\"form-field-field_7b0be24\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-recaptcha elementor-field-group elementor-column elementor-field-group-field_3d89b31 elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field\" id=\"form-field-field_3d89b31\"><div class=\"elementor-g-recaptcha\" data-sitekey=\"6LekVLwhAAAAABFfnz5wkn7TJuRdp1bHanghByKI\" data-type=\"v2_checkbox\" data-theme=\"light\" data-size=\"normal\"><\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">SUBMIT<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-element elementor-element-e4191f0 e-con-full e-flex e-con e-child\" data-id=\"e4191f0\" data-element_type=\"container\" 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