
{"id":3523,"date":"2025-02-25T11:18:09","date_gmt":"2025-02-25T11:18:09","guid":{"rendered":"https:\/\/www.last-ireland.ie\/last-new\/?page_id=3523"},"modified":"2025-03-04T11:53:00","modified_gmt":"2025-03-04T11:53:00","slug":"registration-surgery-module","status":"publish","type":"page","link":"https:\/\/www.last-ireland.ie\/last-new\/registration-surgery-module\/","title":{"rendered":"Registration surgery module"},"content":{"rendered":"<p><!-- Begin myContactForm.com Form HTML --><\/p>\n<form name=\"contactForm\" id=\"contactForm\" method=\"post\"  action=\"https:\/\/www.mycontactform.com\/sendform\/sendform.php\" style=\"width: 100%; border: 0px solid #000000; margin: 0; padding: 0; background-color: #FFFFFF;\">\n<table summary=\"This table contains contact form fields.\" width=\"100%\" cellpadding=\"0\" cellspacing=\"0\">\n<tr style=\"margin: 0; padding: 0;\">\n<td style=\"background-color: #FFFFFF; border-bottom: 0px solid #D8D8D8; padding: 5px; clear: left; margin: 0;\">\n  <label for=\"email\" style=\"float: left; width: 30%; padding-top: 4px; font-family: Arial; color: #000000; font-size: 16px; font-style:italic; font-weight: bold;\">E-mail Address: <span style=\"color: #FF0000\">*<\/span><\/label><br \/>\n  <input name=\"email\" type=\"email\" id=\"email\" size=\"20\" maxlength=\"100\" required=\"required\" style=\"font-family: Arial; font-size: 14px; color: #000000; background-color: #FFFFFF; border: 1px solid #000000; padding: 2px;\" \/>\n  <\/td>\n<\/tr>\n<tr style=\"margin: 0; padding: 0;\">\n<td style=\"background-color: #EFEFEF; border-bottom: 0px solid #D8D8D8; padding: 5px; clear: left; margin: 0;\">\n  <label for=\"q1\" style=\"float: left; width: 30%; padding-top: 4px; font-family: Arial; color: #000000; font-size: 16px; font-style:italic; font-weight: bold;\">Prefix: <\/label> <select name=\"q1\" id=\"q1\" style=\"font-family: Arial; font-size: 14px; color: #000000; background-color: #FFFFFF; border: 1px solid #000000; padding: 2px;\"  ><option value=\"Mr.\">Mr.<\/option><option value=\"Mrs.\">Mrs.<\/option><option value=\"Miss\">Miss<\/option><option value=\"Ms.\">Ms.<\/option><option value=\"Dr.\">Dr.<\/option><option value=\"Other \">Other <\/option><\/select>\n  <\/td>\n<\/tr>\n<tr style=\"margin: 0; 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font-size: 14px; color: #000000; background-color: #FFFFFF; border: 1px solid #000000; padding: 2px;\" \/>\n  <\/td>\n<\/tr>\n<tr style=\"margin: 0; padding: 0;\">\n<td style=\"background-color: #FFFFFF; border-bottom: 0px solid #D8D8D8; padding: 5px; clear: left; margin: 0;\">\n  <label for=\"q11\" style=\"float: left; width: 30%; padding-top: 4px; font-family: Arial; color: #000000; font-size: 16px; font-style:italic; font-weight: bold;\">Organization: <span style=\"color: #FF0000\">*<\/span><\/label> <input name=\"q11\" type=\"text\" id=\"q11\" value=\"\" size=\"20\" maxlength=\"150\" style=\"font-family: Arial; font-size: 14px; color: #000000; background-color: #FFFFFF; border: 1px solid #000000; padding: 2px;\" \/>\n  <\/td>\n<\/tr>\n<tr style=\"margin: 0; padding: 0;\">\n<td style=\"background-color: #EFEFEF; border-bottom: 0px solid #D8D8D8; padding: 5px; clear: left; margin: 0;\">\n  <label for=\"q4\" style=\"float: left; width: 30%; padding-top: 4px; font-family: Arial; color: #000000; font-size: 16px; font-style:italic; font-weight: bold;\">Mobile Phone Number: <span style=\"color: #FF0000\">*<\/span><\/label> <input name=\"q4\" id=\"q4\" type=\"text\" value=\"\" size=\"20\" maxlength=\"100\" style=\"font-family: Arial; font-size: 14px; color: #000000; background-color: #FFFFFF; border: 1px solid #000000; padding: 2px;\" required=\"required\" \/>\n  <\/td>\n<\/tr>\n<tr style=\"margin: 0; padding: 0;\">\n<td style=\"background-color: #FFFFFF; border-bottom: 0px solid #D8D8D8; padding: 5px; clear: left; margin: 0;\">\n  <label for=\"q32\" style=\"float: left; width: 30%; padding-top: 4px; font-family: Arial; color: #000000; font-size: 16px; font-style:italic; font-weight: bold;\">Surgery module Theory 250 Euro <\/label> <input name=\"q32\" id=\"q32\" type=\"checkbox\" value=\"Don't Leave Blank\"   \/>\n  <\/td>\n<\/tr>\n<tr style=\"margin: 0; padding: 0;\">\n<td style=\"background-color: #EFEFEF; border-bottom: 0px solid #D8D8D8; padding: 5px; clear: left; margin: 0;\">\n  <label for=\"q33\" style=\"float: left; width: 30%; padding-top: 4px; font-family: Arial; color: #000000; font-size: 16px; font-style:italic; font-weight: bold;\">Surgery Practical 24th May 25 350 Euro <\/label> <input name=\"q33\" id=\"q33\" type=\"checkbox\" value=\"Don't Leave Blank\"   \/>\n  <\/td>\n<\/tr>\n<tr style=\"margin: 0; padding: 0;\">\n<td style=\"background-color: #FFFFFF; border-bottom: 0px solid #D8D8D8; padding: 5px; clear: left; margin: 0;\">\n  <label for=\"q31\" style=\"float: left; width: 30%; padding-top: 4px; font-family: Arial; color: #000000; font-size: 16px; font-style:italic; font-weight: bold;\">Credit card card <\/label> <\/p>\n<div style=\"font-family: Arial; color: #000000; font-size: 16px; float: left;\"\"><input name=\"q31\" id=\"q31\" type=\"hidden\" value=\"checkbox464679\" \/><input name=\"checkbox31[]\" type=\"checkbox\" value=\"Yes \" \/>Yes <br \/><input name=\"checkbox31[]\" type=\"checkbox\" value=\"No\" \/>No<\/div>\n<div style=\"clear: both;\"><\/div>\n<\/td>\n<\/tr>\n<tr style=\"margin: 0; padding: 0;\">\n<td style=\"background-color: #EFEFEF; border-bottom: 0px solid #D8D8D8; padding: 5px; clear: left; margin: 0;\">\n  <label for=\"q29\" style=\"float: left; width: 30%; padding-top: 4px; font-family: Arial; color: #000000; font-size: 16px; font-style:italic; font-weight: bold;\">Purchase order number <\/label> <input name=\"q29\" id=\"q29\" type=\"text\" value=\"\" size=\"20\" maxlength=\"\" style=\"font-family: Arial; font-size: 14px; color: #000000; background-color: #FFFFFF; border: 1px solid #000000; padding: 2px;\"  \/>\n  <\/td>\n<\/tr>\n<tr style=\"margin: 0; padding: 0;\">\n<td style=\"background-color: #FFFFFF; border-bottom: 0px solid #D8D8D8; padding: 5px; clear: left; margin: 0;\">\n  <label for=\"q27\" style=\"float: left; width: 30%; padding-top: 4px; font-family: Arial; color: #000000; font-size: 16px; font-style:italic; font-weight: bold;\">Comments <\/label> <input name=\"q27\" id=\"q27\" type=\"text\" value=\"\" size=\"20\" maxlength=\"\" style=\"font-family: Arial; font-size: 14px; color: #000000; background-color: #FFFFFF; border: 1px solid #000000; padding: 2px;\"  \/>\n  <\/td>\n<\/tr>\n<tr style=\"margin: 0; padding: 0;\">\n<td style=\"background-color: #EFEFEF; border-bottom: 0px solid #D8D8D8; padding: 5px; clear: left; margin: 0;\">\n  <label for=\"q30\" style=\"float: left; width: 30%; padding-top: 4px; font-family: Arial; color: #000000; font-size: 16px; font-style:italic; font-weight: bold;\">Agree to terms and conditions as per GDPR STATEMENT <span style=\"color: #FF0000\">*<\/span><\/label> <select name=\"q30\" id=\"q30\" style=\"font-family: Arial; font-size: 14px; color: #000000; background-color: #FFFFFF; border: 1px solid #000000; padding: 2px;\" required=\"required\" ><option value=\"Enter choice\">Enter choice<\/option><option value=\"No\">No<\/option><option value=\"Yes\">Yes<\/option><\/select>\n  <\/td>\n<\/tr>\n<tr style=\"margin: 0; padding: 0;\">\n<td style=\"background-color: #FFFFFF; border-bottom: 0px solid #D8D8D8; padding: 5px; clear: left; margin: 0;\">\n<label for=\"verification_image\" style=\"float: left; width: 30%; padding-top: 4px; font-family: Arial; color: #000000; font-size: 16px; font-style:italic; font-weight: bold;\">Verification Code:<\/label><img decoding=\"async\" src=\"https:\/\/www.mycontactform.com\/visver\/gen_img.php?formid=464679&#038;user=Lastt\" alt=\"Visual Verification Image\" id=\"verification_image\" \/> <\/td>\n<\/tr>\n<tr style=\"margin: 0; padding: 0;\">\n<td style=\"background-color: #EFEFEF; border-bottom: 0px solid #D8D8D8; padding: 5px; clear: left; margin: 0;\">\n<label for=\"visver_code\" style=\"float: left; width: 30%; padding-top: 4px; font-family: Arial; color: #000000; font-size: 16px; font-style:italic; font-weight: bold;\">Enter Verification Code: <span style=\"color: #FF0000\">*<\/span><\/label> <input name=\"visver_code\" type=\"text\" id=\"visver_code\" size=\"6\" maxlength=\"6\" style=\"font-family: Arial; font-size: 14px; color: #000000; background-color: #FFFFFF; border: 1px solid #000000; padding: 2px;\" \/>\n <\/td>\n<\/tr>\n<tr style=\"margin: 0; padding: 0;\">\n<td style=\"background-color: #FFFFFF; padding: 5px; clear: left; margin: 0;\">\n<hr style=\"color: #D8D8D8; background-color: #D8D8D8; height: 1px;\" \/>\n <\/td>\n<\/tr>\n<tr style=\"margin: 0; padding: 0;\">\n<td style=\"background-color: #FFFFFF; padding: 5px; clear: left; margin: 0;\">\n   <input name=\"user\" type=\"hidden\" id=\"user\" value=\"Lastt\" \/><br \/>\n   <input name=\"formid\" type=\"hidden\" id=\"formid\" value=\"464679\" \/><br \/>\n   <input name=\"subject\" type=\"hidden\" id=\"subject\" value=\"LAST Ireland Surgery Module\" \/><br \/>\n   <input name=\"submit\" type=\"submit\" value=\"SUBMIT\" style=\"font-family: ; font-size: ; color: ; background-color: ; border:  solid ; padding: 2px;\" \/><br \/>\n   <input name=\"reset\" type=\"reset\" value=\"Reset\" style=\"font-family: ; font-size: ; color: ; background-color: ; border:  solid ; padding: 2px;\" \/><br \/>\n   <input type=\"button\" value=\"Print\" onClick=\"window.print()\" style=\"font-family: ; font-size: ; color: ; background-color: ; border:  solid ; padding: 2px;\" \/>\n <\/td>\n<\/tr>\n<tr style=\"margin: 0; padding: 0;\">\n<td style=\"background-color: #FFFFFF; padding: 5px; clear: left; margin: 0;\">\n<span style=\"color: #FF0000\">*<\/span> <span style=\"font-family: Arial; color: #000000; font-size: 16px;\">Required<\/span> <\/td>\n<\/tr>\n<\/table>\n<\/form>\n<p><!-- End myContactForm.com Form HTML --><\/p>\n","protected":false},"excerpt":{"rendered":"<p>E-mail Address: * Prefix: Mr.Mrs.MissMs.Dr.Other First Name: * Last Name: * Organization: * Mobile Phone Number: * Surgery module Theory 250 Euro Surgery Practical 24th May 25 350 Euro Credit card card<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-3523","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.last-ireland.ie\/last-new\/wp-json\/wp\/v2\/pages\/3523","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.last-ireland.ie\/last-new\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.last-ireland.ie\/last-new\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.last-ireland.ie\/last-new\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.last-ireland.ie\/last-new\/wp-json\/wp\/v2\/comments?post=3523"}],"version-history":[{"count":3,"href":"https:\/\/www.last-ireland.ie\/last-new\/wp-json\/wp\/v2\/pages\/3523\/revisions"}],"predecessor-version":[{"id":3548,"href":"https:\/\/www.last-ireland.ie\/last-new\/wp-json\/wp\/v2\/pages\/3523\/revisions\/3548"}],"wp:attachment":[{"href":"https:\/\/www.last-ireland.ie\/last-new\/wp-json\/wp\/v2\/media?parent=3523"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}