Requested Start Date

Requested End Date

Exchange Frequency

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="First_Name_" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="Last_Name" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="DOB1" as=${html``} />

<${validation.ErrorMessage} errors=${validation.errors} name="Gender" as=${html``} />

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['mf-select1'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="mf-select1" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}]} value=${parent.getValue("mf-select1") ? [{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}].filter(item => item.value === parent.getValue("mf-select1"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "mf-select1")} ref=${() => { register({ name: "mf-select1" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("mf-select1") === '' && false ) { parent.setValue( 'mf-select1', '', true ); parent.handleChange({ target: { name: 'mf-select1', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="mf-select1" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="First_Name_1" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="Last_Name1" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="DOB2" as=${html``} />

<${validation.ErrorMessage} errors=${validation.errors} name="Gender1" as=${html``} />

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['mf-select2'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="mf-select2" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}]} value=${parent.getValue("mf-select2") ? [{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}].filter(item => item.value === parent.getValue("mf-select2"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "mf-select2")} ref=${() => { register({ name: "mf-select2" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("mf-select2") === '' && false ) { parent.setValue( 'mf-select2', '', true ); parent.handleChange({ target: { name: 'mf-select2', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="mf-select2" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="First_Name_2" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="Last_Name2" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="DOB3" as=${html``} />

<${validation.ErrorMessage} errors=${validation.errors} name="Gender2" as=${html``} />

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['mf-select3'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="mf-select3" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}]} value=${parent.getValue("mf-select3") ? [{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}].filter(item => item.value === parent.getValue("mf-select3"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "mf-select3")} ref=${() => { register({ name: "mf-select3" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("mf-select3") === '' && false ) { parent.setValue( 'mf-select3', '', true ); parent.handleChange({ target: { name: 'mf-select3', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="mf-select3" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="First_Name_3" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="Last_Name3" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="DOB4" as=${html``} />

<${validation.ErrorMessage} errors=${validation.errors} name="Gender4" as=${html``} />

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['mf-select4'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="mf-select4" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}]} value=${parent.getValue("mf-select4") ? [{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}].filter(item => item.value === parent.getValue("mf-select4"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "mf-select4")} ref=${() => { register({ name: "mf-select4" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("mf-select4") === '' && false ) { parent.setValue( 'mf-select4', '', true ); parent.handleChange({ target: { name: 'mf-select4', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="mf-select4" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="First_Name_4" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="Last_Name4" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="DOB5" as=${html``} />

<${validation.ErrorMessage} errors=${validation.errors} name="Gender5" as=${html``} />

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['mf-select5'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="mf-select5" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}]} value=${parent.getValue("mf-select5") ? [{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}].filter(item => item.value === parent.getValue("mf-select5"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "mf-select5")} ref=${() => { register({ name: "mf-select5" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("mf-select5") === '' && false ) { parent.setValue( 'mf-select5', '', true ); parent.handleChange({ target: { name: 'mf-select5', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="mf-select5" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="First_Name_5" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="Last_Name5" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="DOB6" as=${html``} />

<${validation.ErrorMessage} errors=${validation.errors} name="Gender6" as=${html``} />

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['mf-select6'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="mf-select6" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}]} value=${parent.getValue("mf-select6") ? [{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}].filter(item => item.value === parent.getValue("mf-select6"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "mf-select6")} ref=${() => { register({ name: "mf-select6" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("mf-select6") === '' && false ) { parent.setValue( 'mf-select6', '', true ); parent.handleChange({ target: { name: 'mf-select6', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="mf-select6" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="First_Name_6" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="Last_Name4" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="DOB7" as=${html``} />

<${validation.ErrorMessage} errors=${validation.errors} name="Gender7" as=${html``} />

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['mf-select7'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="mf-select7" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}]} value=${parent.getValue("mf-select7") ? [{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}].filter(item => item.value === parent.getValue("mf-select7"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "mf-select7")} ref=${() => { register({ name: "mf-select7" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("mf-select7") === '' && false ) { parent.setValue( 'mf-select7', '', true ); parent.handleChange({ target: { name: 'mf-select7', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="mf-select7" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="First_Name_7" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="Last_Name6" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="DOB8" as=${html``} />

<${validation.ErrorMessage} errors=${validation.errors} name="Gender8" as=${html``} />

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['mf-select8'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="mf-select8" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}]} value=${parent.getValue("mf-select8") ? [{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}].filter(item => item.value === parent.getValue("mf-select8"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "mf-select8")} ref=${() => { register({ name: "mf-select8" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("mf-select8") === '' && false ) { parent.setValue( 'mf-select8', '', true ); parent.handleChange({ target: { name: 'mf-select8', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="mf-select8" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="First_Name_7" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="Last_Name7" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="DOB9" as=${html``} />

<${validation.ErrorMessage} errors=${validation.errors} name="Gender8" as=${html``} />

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['mf-select9'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="mf-select9" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}]} value=${parent.getValue("mf-select9") ? [{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}].filter(item => item.value === parent.getValue("mf-select9"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "mf-select9")} ref=${() => { register({ name: "mf-select9" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("mf-select9") === '' && false ) { parent.setValue( 'mf-select9', '', true ); parent.handleChange({ target: { name: 'mf-select9', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="mf-select9" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="First_Name_8" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="Last_Name8" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="DOB10" as=${html``} />

<${validation.ErrorMessage} errors=${validation.errors} name="Gender9" as=${html``} />

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['mf-select10'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="mf-select10" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}]} value=${parent.getValue("mf-select10") ? [{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}].filter(item => item.value === parent.getValue("mf-select10"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "mf-select10")} ref=${() => { register({ name: "mf-select10" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("mf-select10") === '' && false ) { parent.setValue( 'mf-select10', '', true ); parent.handleChange({ target: { name: 'mf-select10', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="mf-select10" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="First_Name_9" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="Last_Name9" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="DOB11" as=${html``} />

<${validation.ErrorMessage} errors=${validation.errors} name="Gender10" as=${html``} />

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['mf-select11'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="mf-select11" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}]} value=${parent.getValue("mf-select11") ? [{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}].filter(item => item.value === parent.getValue("mf-select11"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "mf-select11")} ref=${() => { register({ name: "mf-select11" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("mf-select11") === '' && false ) { parent.setValue( 'mf-select11', '', true ); parent.handleChange({ target: { name: 'mf-select11', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="mf-select11" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="First_Name_10" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="Last_Name11" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="DOB12" as=${html``} />

<${validation.ErrorMessage} errors=${validation.errors} name="Gender11" as=${html``} />

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['mf-select12'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="mf-select12" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}]} value=${parent.getValue("mf-select12") ? [{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}].filter(item => item.value === parent.getValue("mf-select12"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "mf-select12")} ref=${() => { register({ name: "mf-select12" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("mf-select12") === '' && false ) { parent.setValue( 'mf-select12', '', true ); parent.handleChange({ target: { name: 'mf-select12', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="mf-select12" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="First_Name_11" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="Last_Name12" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="DOB13" as=${html``} />

<${validation.ErrorMessage} errors=${validation.errors} name="Gender12" as=${html``} />

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['mf-select13'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="mf-select13" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}]} value=${parent.getValue("mf-select13") ? [{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}].filter(item => item.value === parent.getValue("mf-select13"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "mf-select13")} ref=${() => { register({ name: "mf-select13" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("mf-select13") === '' && false ) { parent.setValue( 'mf-select13', '', true ); parent.handleChange({ target: { name: 'mf-select13', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="mf-select13" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="First_Name_12" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="Last_Name13" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="DOB14" as=${html``} />

<${validation.ErrorMessage} errors=${validation.errors} name="Gender13" as=${html``} />

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['mf-select14'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="mf-select14" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}]} value=${parent.getValue("mf-select14") ? [{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}].filter(item => item.value === parent.getValue("mf-select14"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "mf-select14")} ref=${() => { register({ name: "mf-select14" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("mf-select14") === '' && false ) { parent.setValue( 'mf-select14', '', true ); parent.handleChange({ target: { name: 'mf-select14', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="mf-select14" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="First_Name_13" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="Last_Name14" as=${html``} />

{ parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el) }} /> <${validation.ErrorMessage} errors=${validation.errors} name="DOB15" as=${html``} />

<${validation.ErrorMessage} errors=${validation.errors} name="Gender14" as=${html``} />

<${props.Select} className=${"mf-input mf-input-select " + ( validation.errors['mf-select15'] ? 'mf-invalid' : '' )} classNamePrefix="mf_select" name="mf-select15" placeholder="${ parent.decodeEntities(`Select`) } " isSearchable=${false} options=${[{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}]} value=${parent.getValue("mf-select15") ? [{"label":"Whole Body OSL","value":"Whole Body OSL","isDisabled":false},{"label":"Whole Body TLD","value":"Whole Body TLD","isDisabled":false},{"label":"Ring OSL","value":"Ring OSL","isDisabled":false},{"label":"Ring TLD","value":"Ring TLD","isDisabled":false},{"label":"Fetal Badge","value":"Fetal Badge","isDisabled":false}].filter(item => item.value === parent.getValue("mf-select15"))[0] : []} onChange=${(e)=> parent.handleSelect(e, "mf-select15")} ref=${() => { register({ name: "mf-select15" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false})); if ( parent.getValue("mf-select15") === '' && false ) { parent.setValue( 'mf-select15', '', true ); parent.handleChange({ target: { name: 'mf-select15', value: '' } }); } }} /> <${validation.ErrorMessage} errors=${validation.errors} name="mf-select15" as=${html``} />