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  1. <form action="https://docs.google.com/forms/d/e/1FAIpQLSfIIec4ucX4GmlBqTxhjSEY1SBhhc4GFHrp66SqgWn-2HSciw/formResponse" target="_self" method="POST" id="mG61Hd">
  2. <div class="freebirdFormviewerViewFormCard">
  3. <div class="freebirdFormviewerViewAccentBanner freebirdAccentBackground">
  4. </div>
  5. <div class="freebirdFormviewerViewFormContent ">
  6. <div class="freebirdFormviewerViewHeaderHeader">
  7. <div class="freebirdFormviewerViewHeaderTitleRow">
  8. <div class="freebirdFormviewerViewHeaderTitle" dir="auto" role="heading" aria-level="1">
  9. Get In Touch</div>
  10. </div>
  11. <div class="freebirdFormviewerViewHeaderRequiredLegend" aria-hidden="true" dir="auto">
  12. * Required</div>
  13. </div>
  14. <div class=freebirdFormviewerViewItemList role="list">
  15. <div role="listitem" class="freebirdFormviewerViewItemsItemItem freebirdFormviewerViewItemsTextTextItem" jsname="ibnC6b" jscontroller="rDGJeb"jsaction="sPvj8e:e4JwSe,vwKRrd;"data-required="true"data-input="L9xHkb"data-item-id="1183426638">
  16. <div class="freebirdFormviewerViewItemsItemItemheader">
  17. <div class="freebirdFormviewerViewItemsItemItemTitleContainer">
  18. <div class="freebirdFormviewerViewItemsItemItemTitle" dir="auto"role="heading" aria-level="2" aria-describedby="i.desc.1183426638">
  19. Full Name <span class="freebirdFormviewerViewItemsItemRequiredAsterisk" aria-hidden="true">
  20. *</span>
  21. </div>
  22. <div class="freebirdFormviewerViewItemsItemItemHelpText" id="i.desc.1183426638" dir="auto">
  23. </div>
  24. </div>
  25. </div>
  26. <div class="freebirdFormviewerViewItemsTextItemWrapper">
  27. <div class="quantumWizTextinputPaperinputEl freebirdFormviewerViewItemsTextShortText freebirdThemedInput" jscontroller="pxq3x" jsaction="clickonly:KjsqPd; focus:Jt1EX; blur:fpfTEe; input:Lg5SV;" jsshadow jsname="W85ice">
  28. <div class="quantumWizTextinputPaperinputMainContent exportContent">
  29. <div class="quantumWizTextinputPaperinputContentArea">
  30. <div class="quantumWizTextinputPaperinputInputArea">
  31. <input type="text" class="quantumWizTextinputPaperinputInput exportInput" jsname="YPqjbf" autocomplete="off" tabindex="0" aria-label="Full Name" aria-describedby="i.desc.1183426638 i.err.1183426638" name="Get In Touch" value="" required dir="auto" data-initial-dir="auto" data-initial-value="" />
  32. <div jsname="LwH6nd" class="quantumWizTextinputPaperinputPlaceholder exportLabel" >
  33. Your answer</div>
  34. </div>
  35. <div class="quantumWizTextinputPaperinputUnderline exportUnderline">
  36. </div>
  37. <div jsname="XmnwAc" class="quantumWizTextinputPaperinputFocusUnderline exportFocusUnderline">
  38. </div>
  39. </div>
  40. </div>
  41. <div jsname="ty6ygf" class="quantumWizTextinputPaperinputHint exportHint">
  42. </div>
  43. </div>
  44. </div>
  45. <input type="hidden" name="entry.206415242" jsname="L9xHkb">
  46. <div jsname="XbIQze" class="freebirdFormviewerViewItemsItemErrorMessage" id="i.err.1183426638" role="alert">
  47. </div>
  48. </div>
  49. <div role="listitem" class="freebirdFormviewerViewItemsItemItem freebirdFormviewerViewItemsTextTextItem" jsname="ibnC6b" jscontroller="rDGJeb"jsaction="sPvj8e:e4JwSe,vwKRrd;"data-required="true"data-input="L9xHkb"data-item-id="1996240844">
  50. <div class="freebirdFormviewerViewItemsItemItemheader">
  51. <div class="freebirdFormviewerViewItemsItemItemTitleContainer">
  52. <div class="freebirdFormviewerViewItemsItemItemTitle" dir="auto"role="heading" aria-level="2" aria-describedby="i.desc.1996240844">
  53. Email Address <span class="freebirdFormviewerViewItemsItemRequiredAsterisk" aria-hidden="true">
  54. *</span>
  55. </div>
  56. <div class="freebirdFormviewerViewItemsItemItemHelpText" id="i.desc.1996240844" dir="auto">
  57. </div>
  58. </div>
  59. </div>
  60. <div class="freebirdFormviewerViewItemsTextItemWrapper">
  61. <div class="quantumWizTextinputPaperinputEl freebirdFormviewerViewItemsTextShortText freebirdThemedInput" jscontroller="pxq3x" jsaction="clickonly:KjsqPd; focus:Jt1EX; blur:fpfTEe; input:Lg5SV;" jsshadow jsname="W85ice">
  62. <div class="quantumWizTextinputPaperinputMainContent exportContent">
  63. <div class="quantumWizTextinputPaperinputContentArea">
  64. <div class="quantumWizTextinputPaperinputInputArea">
  65. <input type="text" class="quantumWizTextinputPaperinputInput exportInput" jsname="YPqjbf" autocomplete="off" tabindex="0" aria-label="Email Address" aria-describedby="i.desc.1996240844 i.err.1996240844" name="Get In Touch" value="" required dir="auto" data-initial-dir="auto" data-initial-value="" />
  66. <div jsname="LwH6nd" class="quantumWizTextinputPaperinputPlaceholder exportLabel" >
  67. Your answer</div>
  68. </div>
  69. <div class="quantumWizTextinputPaperinputUnderline exportUnderline">
  70. </div>
  71. <div jsname="XmnwAc" class="quantumWizTextinputPaperinputFocusUnderline exportFocusUnderline">
  72. </div>
  73. </div>
  74. </div>
  75. <div jsname="ty6ygf" class="quantumWizTextinputPaperinputHint exportHint">
  76. </div>
  77. </div>
  78. </div>
  79. <input type="hidden" name="entry.1427540220" jsname="L9xHkb">
  80. <div jsname="XbIQze" class="freebirdFormviewerViewItemsItemErrorMessage" id="i.err.1996240844" role="alert">
  81. </div>
  82. </div>
  83. <div role="listitem" class="freebirdFormviewerViewItemsItemItem freebirdFormviewerViewItemsTextTextItem" jsname="ibnC6b" jscontroller="rDGJeb"jsaction="sPvj8e:e4JwSe,vwKRrd;"data-input="L9xHkb"data-item-id="291391911">
  84. <div class="freebirdFormviewerViewItemsItemItemheader">
  85. <div class="freebirdFormviewerViewItemsItemItemTitleContainer">
  86. <div class="freebirdFormviewerViewItemsItemItemTitle" dir="auto"role="heading" aria-level="2" aria-describedby="i.desc.291391911">
  87. Medical Association</div>
  88. <div class="freebirdFormviewerViewItemsItemItemHelpText" id="i.desc.291391911" dir="auto">
  89. </div>
  90. </div>
  91. </div>
  92. <div class="freebirdFormviewerViewItemsTextItemWrapper">
  93. <div class="quantumWizTextinputPaperinputEl freebirdFormviewerViewItemsTextShortText freebirdThemedInput" jscontroller="pxq3x" jsaction="clickonly:KjsqPd; focus:Jt1EX; blur:fpfTEe; input:Lg5SV;" jsshadow jsname="W85ice">
  94. <div class="quantumWizTextinputPaperinputMainContent exportContent">
  95. <div class="quantumWizTextinputPaperinputContentArea">
  96. <div class="quantumWizTextinputPaperinputInputArea">
  97. <input type="text" class="quantumWizTextinputPaperinputInput exportInput" jsname="YPqjbf" autocomplete="off" tabindex="0" aria-label="Medical Association" aria-describedby="i.desc.291391911 i.err.291391911" name="Get In Touch" value="" dir="auto" data-initial-dir="auto" data-initial-value="" />
  98. <div jsname="LwH6nd" class="quantumWizTextinputPaperinputPlaceholder exportLabel" >
  99. Your answer</div>
  100. </div>
  101. <div class="quantumWizTextinputPaperinputUnderline exportUnderline">
  102. </div>
  103. <div jsname="XmnwAc" class="quantumWizTextinputPaperinputFocusUnderline exportFocusUnderline">
  104. </div>
  105. </div>
  106. </div>
  107. <div jsname="ty6ygf" class="quantumWizTextinputPaperinputHint exportHint">
  108. </div>
  109. </div>
  110. </div>
  111. <input type="hidden" name="entry.1993141127" jsname="L9xHkb">
  112. <div jsname="XbIQze" class="freebirdFormviewerViewItemsItemErrorMessage" id="i.err.291391911" role="alert">
  113. </div>
  114. </div>
  115. </div>
  116. <div class="freebirdFormviewerViewNavigationNavControls" jscontroller="lSvzH" jsaction="rcuQ6b:npT2md;JIbuQc:V3upec(GeGHKb),HiUbje(M2UYVd),NPBnCf(OCpkoe)" data-shuffle-seed="-2524542490270280579">
  117. <div class="freebirdFormviewerViewNavigationButtonsAndProgress">
  118. <div class="freebirdFormviewerViewNavigationButtons">
  119. <div role="button" class="quantumWizButtonPaperbuttonEl quantumWizButtonPaperbuttonFlat quantumWizButtonPaperbuttonDark quantumWizButtonPaperbutton2El2 freebirdFormviewerViewNavigationSubmitButton" jscontroller="VXdfxd" jsaction="click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventMouseEvents=true|preventDefault=true); touchcancel:JMtRjd;focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;" jsshadow jsname="M2UYVd" aria-disabled="false" tabindex="0" >
  120. <div class="quantumWizButtonPaperbuttonRipple exportInk" jsname="ksKsZd">
  121. </div>
  122. <div class="quantumWizButtonPaperbuttonFocusOverlay exportOverlay">
  123. </div>
  124. <content class="quantumWizButtonPaperbuttonContent">
  125. <span class="quantumWizButtonPaperbuttonLabel">
  126. Submit</span>
  127. </content>
  128. </div>
  129. </div>
  130. </div>
  131. <div class="freebirdFormviewerViewNavigationPasswordWarning">
  132. Never submit passwords through Google Forms.</div>
  133. </div>
  134. <input type="hidden" name="fvv" value="1">
  135. <input type="hidden" name="draftResponse" value="[,,"-2524542490270280579"]">
  136.  
  137. <input type="hidden" name="pageHistory" value="0">
  138.  
  139. <input type="hidden" name="fbzx" value="-2524542490270280579">
  140.  
  141. </div>
  142.  
  143. </div>
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