{"id":6182,"date":"2026-08-26T02:27:32","date_gmt":"2026-08-26T02:27:32","guid":{"rendered":"https:\/\/gloryassistance.com\/?page_id=6182"},"modified":"2026-08-29T13:38:08","modified_gmt":"2026-08-29T13:38:08","slug":"medical-evaluation","status":"publish","type":"page","link":"https:\/\/gloryassistance.com\/fr\/medical-evaluation\/","title":{"rendered":"Medical Evaluation Page"},"content":{"rendered":"<!-- =========================================================\n     GLORY ASSISTANCE\n     MEDICAL + VISA EVALUATION FUNNEL \u2014 aVERSION 5\n     Brand green: #2aa897\n     ========================================================= -->\n\n<style>\n.ga-eval,.ga-eval *{\n    box-sizing:border-box;\n}\n\n.ga-eval{\n    --green:#2aa897;\n    --green-dark:#218f83;\n    --green-soft:#eef9f7;\n    --dark:#17201d;\n    --text:#596761;\n    --muted:#78857f;\n    --border:#dce7e3;\n    --error:#c94d4d;\n    --error-soft:#fff7f7;\n    max-width:1080px;\n    margin:0 auto;\n    padding:35px 18px 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margin:0 0 30px;\n    color:var(--text);\n    font-size:15px;\n    line-height:1.7;\n}\n\n\/* =========================\n   REQUIRED \/ OPTIONAL\n   ========================= *\/\n\n.ga-required{\n    color:var(--error);\n    font-weight:900;\n}\n\n.ga-optional{\n    margin-left:7px;\n    color:#8a9792;\n    font-size:11px;\n    font-weight:700;\n}\n\n.ga-required-note{\n    display:inline-flex;\n    align-items:center;\n    gap:5px;\n    margin-bottom:22px;\n    padding:7px 11px;\n    border-radius:8px;\n    background:#f7faf9;\n    color:#66756f;\n    font-size:11px;\n    font-weight:700;\n}\n\n.ga-required-note strong{\n    color:var(--error);\n    font-size:14px;\n}\n\n\/* =========================\n   OPTIONS\n   ========================= *\/\n\n.ga-options{\n    display:grid;\n    grid-template-columns:repeat(2,minmax(0,1fr));\n    gap:13px;\n}\n\n.ga-option{\n    position:relative;\n}\n\n.ga-option input{\n    position:absolute;\n    opacity:0;\n    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.ga-select,\n.ga-field.has-error .ga-textarea{\n    border-color:var(--error) !important;\n    background:var(--error-soft);\n    box-shadow:0 0 0 2px rgba(201,77,77,.07);\n}\n\n.ga-option-group.has-error{\n    padding:10px;\n    border:1px solid var(--error);\n    border-radius:14px;\n    background:var(--error-soft);\n}\n\n.ga-error-message{\n    display:none;\n    margin-top:7px;\n    color:var(--error);\n    font-size:11px;\n    font-weight:750;\n}\n\n.ga-error-message.visible{\n    display:block;\n}\n\n.ga-error-global{\n    display:none;\n    margin-top:15px;\n    padding:12px 14px;\n    border:1px solid #efd5d5;\n    border-radius:10px;\n    background:var(--error-soft);\n    color:var(--error);\n    font-size:12px;\n    font-weight:750;\n}\n\n.ga-error-global.visible{\n    display:block;\n}\n\n\/* =========================\n   CONDITIONAL\n   ========================= *\/\n\n.ga-conditional{\n    display:none;\n    margin-top:20px;\n    padding:22px;\n    border:1px solid #dcece7;\n    border-radius:15px;\n    background:#f7fbfa;\n}\n\n.ga-conditional.visible{\n    display:block;\n    animation:gaConditionalIn .2s ease;\n}\n\n@keyframes gaConditionalIn{\n    from{\n        opacity:0;\n        transform:translateY(4px);\n    }\n    to{\n        opacity:1;\n        transform:translateY(0);\n    }\n}\n\n\/* =========================\n   MULTI COUNTRY\n   ========================= *\/\n\n.ga-country-picker{\n    display:flex;\n    gap:10px;\n    align-items:flex-start;\n}\n\n.ga-country-picker .ga-select{\n    flex:1;\n}\n\n.ga-add-country{\n    min-height:51px;\n    padding:0 18px;\n    border:1px solid var(--green);\n    border-radius:11px;\n    background:var(--green-soft);\n    color:var(--green-dark);\n    font-size:12px;\n    font-weight:800;\n    cursor:pointer;\n}\n\n.ga-selected-countries{\n    display:flex;\n    flex-wrap:wrap;\n    gap:8px;\n    margin-top:13px;\n}\n\n.ga-country-tag{\n    display:inline-flex;\n    align-items:center;\n    gap:8px;\n    padding:8px 11px;\n    border-radius:20px;\n    background:var(--green-soft);\n    color:#176f65;\n    font-size:12px;\n    font-weight:750;\n}\n\n.ga-country-remove{\n    border:0;\n    background:none;\n    color:#65817a;\n    font-weight:900;\n    cursor:pointer;\n}\n\n\/* =========================\n   INFO \/ NOTE\n   ========================= *\/\n\n.ga-section-note{\n    margin:0 0 28px;\n    padding:16px 18px;\n    border-left:3px solid var(--green);\n    border-radius:0 12px 12px 0;\n    background:#f6fbf9;\n    color:#596b64;\n    font-size:13px;\n    line-height:1.65;\n}\n\n.ga-info{\n    display:flex;\n    gap:12px;\n    padding:16px 17px;\n    margin-top:22px;\n    border:1px solid #dcece7;\n    border-radius:13px;\n    background:#f6fbf9;\n}\n\n.ga-info-mark{\n    width:22px;\n    height:22px;\n    flex:0 0 22px;\n    display:flex;\n    align-items:center;\n    justify-content:center;\n    border-radius:50%;\n    background:var(--green);\n    color:#fff;\n    font-size:12px;\n    font-weight:800;\n}\n\n.ga-info-text{\n    color:#5a6c65;\n    font-size:12px;\n    line-height:1.6;\n}\n\n\/* =========================\n   UPLOAD\n   ========================= *\/\n\n.ga-upload{\n    padding:27px;\n    text-align:center;\n    border:1.5px dashed #bdd6cf;\n    border-radius:15px;\n    background:#fbfdfc;\n}\n\n.ga-upload-icon{\n    width:45px;\n    height:45px;\n    margin:0 auto 12px;\n    display:flex;\n    align-items:center;\n    justify-content:center;\n    border-radius:13px;\n    background:var(--green-soft);\n    color:var(--green-dark);\n    font-size:20px;\n    font-weight:800;\n}\n\n.ga-upload-title{\n    margin-bottom:6px;\n    font-size:14px;\n    font-weight:800;\n}\n\n.ga-upload-text{\n    margin-bottom:15px;\n    color:var(--muted);\n    font-size:12px;\n    line-height:1.5;\n}\n\n\/* =========================\n   CONSENT\n   ========================= *\/\n\n.ga-consent-box{\n    margin-top:25px;\n    padding:20px;\n    border:1px solid var(--border);\n    border-radius:15px;\n    background:#fbfdfc;\n}\n\n.ga-consent-item{\n    display:flex;\n    align-items:flex-start;\n    gap:12px;\n    margin-bottom:15px;\n}\n\n.ga-consent-item:last-child{\n    margin-bottom:0;\n}\n\n.ga-consent-item input{\n    width:18px;\n    height:18px;\n    flex:0 0 18px;\n    margin-top:2px;\n    accent-color:var(--green);\n    cursor:pointer;\n}\n\n.ga-consent-item label{\n    color:#465650;\n    font-size:12px;\n    line-height:1.6;\n    cursor:pointer;\n}\n\n.ga-consent-box.has-error{\n    border-color:var(--error);\n    background:var(--error-soft);\n}\n\n.ga-consent-error{\n    display:none;\n    margin-top:10px;\n    color:var(--error);\n    font-size:11px;\n    font-weight:750;\n}\n\n.ga-consent-error.visible{\n    display:block;\n}\n\n\/* =========================\n   ACTIONS\n   ========================= *\/\n\n.ga-actions{\n    display:flex;\n    justify-content:space-between;\n    align-items:center;\n    gap:15px;\n    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margin:0 0 13px;\n    font-size:29px;\n}\n\n.ga-success p{\n    color:var(--text);\n    font-size:14px;\n    line-height:1.7;\n}\n\n.ga-reference{\n    display:inline-block;\n    padding:11px 17px;\n    border-radius:9px;\n    background:#f5faf9;\n    color:var(--green-dark);\n    font-size:13px;\n    font-weight:800;\n}\n\n\/* =========================\n   MOBILE\n   ========================= *\/\n\n@media(max-width:760px){\n\n    .ga-eval{\n        padding:15px 10px 40px;\n    }\n\n    .ga-eval-card{\n        border-radius:18px;\n    }\n\n    .ga-eval-header{\n        padding:21px 19px 18px;\n    }\n\n    .ga-eval-content{\n        padding:34px 20px 35px;\n    }\n\n    .ga-welcome h1{\n        font-size:28px;\n    }\n\n    .ga-step h2{\n        font-size:25px;\n    }\n\n    .ga-options{\n        grid-template-columns:1fr;\n    }\n\n    .ga-field-grid{\n        grid-template-columns:1fr;\n        gap:0;\n    }\n\n    .ga-country-picker{\n        flex-direction:column;\n    }\n\n    .ga-country-picker .ga-select,\n    .ga-add-country{\n        width:100%;\n    }\n\n    .ga-actions{\n        flex-direction:column-reverse;\n        align-items:stretch;\n    }\n\n    .ga-btn{\n        width:100%;\n    }\n\n    .ga-review-row{\n        flex-direction:column;\n        gap:5px;\n    }\n\n    .ga-review-value{\n        max-width:100%;\n        text-align:left;\n    }\n}\n\n@media(max-width:430px){\n\n    .ga-eval-content{\n        padding:29px 16px 30px;\n    }\n\n    .ga-welcome h1{\n        font-size:25px;\n    }\n\n    .ga-step h2{\n        font-size:23px;\n    }\n\n    .ga-option label{\n        min-height:64px;\n        padding:15px;\n    }\n}\n\n\/* =========================================================\n   GLORY ASSISTANCE \u2014 FINAL VISUAL POLISH\n   Visual-only layer: form logic and field IDs unchanged.\n   ========================================================= *\/\n\nbody:has(.ga-eval) .entry-title,\nbody:has(.ga-eval) .page-title{\n    display:none !important;\n}\n\nbody:has(.ga-eval) .site-content,\nbody:has(.ga-eval) .content-area{\n    padding-top:0 !important;\n}\n\nbody:has(.ga-eval){\n    background:#f7faf9;\n}\n\n.ga-eval{\n    max-width:1160px !important;\n    padding:38px 20px 80px !important;\n}\n\n.ga-eval-card{\n    border:1px solid #e2ece8 !important;\n    border-radius:22px !important;\n    box-shadow:0 12px 35px rgba(23,32,29,.055) !important;\n}\n\n.ga-eval-header{\n    padding:20px 38px 18px !important;\n    background:#fff !important;\n}\n\n.ga-eval-brand{\n    margin-bottom:16px !important;\n}\n\n.ga-eval-brand-dot{\n    width:8px !important;\n    height:8px !important;\n}\n\n.ga-progress-track{\n    height:5px !important;\n}\n\n.ga-eval-content{\n    padding:54px 72px 60px !important;\n}\n\n.ga-welcome{\n    max-width:760px !important;\n}\n\n.ga-welcome-icon{\n    width:auto !important;\n    max-width:250px !important;\n    min-height:74px !important;\n    margin-bottom:26px !important;\n    padding:13px 22px !important;\n    border:1px solid #dcefe9 !important;\n    background:#f2faf7 !important;\n}\n\n.ga-welcome-logo img{\n    max-width:195px !important;\n}\n\n.ga-welcome h1{\n    font-size:38px !important;\n    line-height:1.12 !important;\n}\n\n.ga-welcome p{\n    max-width:680px !important;\n    font-size:15px !important;\n}\n\n.ga-welcome-note{\n    border:1px solid #e0eee9 !important;\n    background:#fff !important;\n}\n\n.ga-step h2{\n    font-size:31px !important;\n}\n\n.ga-step-description{\n    max-width:780px !important;\n}\n\n.ga-required-note{\n    border:1px solid #e5eeeb !important;\n    background:#f9fbfa !important;\n}\n\n.ga-options{\n    gap:14px !important;\n}\n\n.ga-option label{\n    min-height:66px !important;\n    border-color:#dfe9e5 !important;\n    border-radius:13px !important;\n    box-shadow:0 1px 2px rgba(23,32,29,.025);\n}\n\n.ga-option label:hover{\n    border-color:#8fcac0 !important;\n    box-shadow:0 4px 14px rgba(42,168,151,.06);\n    transform:translateY(-1px);\n}\n\n.ga-option input:checked + label{\n    box-shadow:0 0 0 3px rgba(42,168,151,.07) !important;\n}\n\n.ga-input,\n.ga-select,\n.ga-textarea{\n    border-color:#d9e5e1 !important;\n    border-radius:11px !important;\n}\n\n.ga-input:hover,\n.ga-select:hover,\n.ga-textarea:hover{\n    border-color:#b9d4cd !important;\n}\n\n.ga-conditional{\n    border-color:#dfece8 !important;\n    background:#f8fcfa !important;\n}\n\n.ga-section-note{\n    border:1px solid #dfede8 !important;\n    border-left:3px solid var(--green) !important;\n    background:#f7fbf9 !important;\n}\n\n.ga-info{\n    border-color:#dfece8 !important;\n    background:#f7fbf9 !important;\n}\n\n.ga-actions{\n    margin-top:42px !important;\n    padding-top:25px !important;\n}\n\n.ga-btn{\n    min-height:49px !important;\n    border-radius:10px !important;\n    letter-spacing:.005em;\n}\n\n.ga-btn-primary{\n    box-shadow:0 5px 14px rgba(42,168,151,.14);\n}\n\n.ga-btn-primary:hover{\n    box-shadow:0 7px 17px rgba(42,168,151,.18);\n}\n\n.ga-review-section{\n    border-color:#e0e9e6 !important;\n    box-shadow:0 2px 8px rgba(23,32,29,.025);\n}\n\n.ga-review-title{\n    background:#f7faf9 !important;\n}\n\n.ga-success{\n    max-width:720px !important;\n}\n\n.ga-success-icon{\n    width:72px !important;\n    height:72px !important;\n    border:1px solid #d9eee8 !important;\n    background:#f0faf6 !important;\n}\n\n.ga-reference{\n    border:1px solid #dcece7 !important;\n    background:#f7fbf9 !important;\n}\n\n@media(max-width:760px){\n    .ga-eval{\n        padding:18px 10px 45px !important;\n    }\n    .ga-eval-card{\n        border-radius:18px !important;\n    }\n    .ga-eval-header{\n        padding:18px 18px 16px !important;\n    }\n    .ga-eval-content{\n        padding:38px 20px 40px !important;\n    }\n    .ga-welcome h1{\n        font-size:29px !important;\n    }\n    .ga-step h2{\n        font-size:25px !important;\n    }\n}\n\n@media(max-width:430px){\n    .ga-eval-content{\n        padding:31px 16px 34px !important;\n    }\n    .ga-welcome-icon{\n        max-width:220px !important;\n    }\n    .ga-welcome-logo img{\n        max-width:175px !important;\n    }\n}\n\n<\/style>\n\n\n<div class=\"ga-eval\" id=\"gaMedicalEvaluation\">\n\n<div class=\"ga-eval-card\">\n\n<!-- =====================================================\n     HEADER\n     ===================================================== -->\n\n<div class=\"ga-eval-header\">\n\n    <div class=\"ga-eval-brand\">\n        <span class=\"ga-eval-brand-dot\"><\/span>\n        <span class=\"ga-eval-brand-name\">\n            Glory Assistance\n        <\/span>\n    <\/div>\n\n    <div class=\"ga-progress-top\">\n        <span class=\"ga-progress-title\">\n            Evaluation\n        <\/span>\n\n        <span\n            class=\"ga-progress-number\"\n            id=\"gaProgressNumber\">\n            Getting started\n        <\/span>\n    <\/div>\n\n    <div class=\"ga-progress-track\">\n        <div\n            class=\"ga-progress-fill\"\n            id=\"gaProgressFill\">\n        <\/div>\n    <\/div>\n\n<\/div>\n\n\n<div class=\"ga-eval-content\">\n\n\n<!-- =====================================================\n     STEP 0 \u2014 WELCOME\n     ===================================================== -->\n\n<section class=\"ga-step active\" data-step=\"0\">\n\n<div class=\"ga-welcome\">\n\n    <div class=\"ga-welcome-icon ga-welcome-logo\">\n        <img decoding=\"async\" src=\"https:\/\/gloryassistance.com\/wp-content\/uploads\/2026\/05\/cropped-Glory-Assistance-Main2-1.png\" alt=\"Glory Assistance\" title=\"Medical Evaluation Page\">\n    <\/div>\n\n    <div class=\"ga-eyebrow\">\n        Glory Assistance Evaluation\n    <\/div>\n\n    <h1>\n        Let&#8217;s understand your situation\n    <\/h1>\n\n    <p>\n        Answer a few questions about your medical treatment\n        needs and travel plans. Your answers will help Glory\n        Assistance understand your situation and determine\n        how we may assist you.\n    <\/p>\n\n    <div class=\"ga-welcome-note\">\n        Takes only a few minutes\n    <\/div>\n\n<\/div>\n\n<div class=\"ga-actions\">\n    <span><\/span>\n\n    <button\n        type=\"button\"\n        class=\"ga-btn ga-btn-primary\"\n        data-ga-action=\"next\">\n        Start Evaluation \u2192\n    <\/button>\n<\/div>\n\n<\/section>\n\n\n<!-- =====================================================\n     STEP 1 \u2014 ASSISTANCE\n     ===================================================== -->\n\n<section class=\"ga-step\" data-step=\"1\">\n\n<div class=\"ga-step-eyebrow\">Step 1<\/div>\n\n<h2>\n    What type of assistance are you looking for?\n<\/h2>\n\n<p class=\"ga-step-description\">\n    Choose the option that best describes what you need\n    from Glory Assistance.\n<\/p>\n\n<div class=\"ga-required-note\">\n    <strong>*<\/strong> Required\n<\/div>\n\n<div class=\"ga-option-group\" id=\"groupAssistance\">\n\n<div class=\"ga-options\">\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"assistance_type\"\n               id=\"gaMedicalOnly\"\n               value=\"Medical treatment abroad\">\n        <label for=\"gaMedicalOnly\">\n            <span class=\"ga-radio\"><\/span>\n            Medical treatment abroad\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"assistance_type\"\n               id=\"gaMedicalVisa\"\n               value=\"Medical treatment + visa assistance\">\n        <label for=\"gaMedicalVisa\">\n            <span class=\"ga-radio\"><\/span>\n            Medical treatment + visa assistance\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"assistance_type\"\n               id=\"gaMedicalUnsure\"\n               value=\"Not sure yet\">\n        <label for=\"gaMedicalUnsure\">\n            <span class=\"ga-radio\"><\/span>\n            I&#8217;m not sure yet\n        <\/label>\n    <\/div>\n\n<\/div>\n\n<\/div>\n\n<div\n    class=\"ga-error-global\"\n    id=\"gaError1\">\n    Please select one option to continue.\n<\/div>\n\n<div class=\"ga-actions\">\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-secondary\"\n    data-ga-action=\"back\">\n    \u2190 Back\n<\/button>\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-primary\"\n    data-ga-action=\"next\">\n    Continue \u2192\n<\/button>\n\n<\/div>\n\n<\/section>\n\n\n<!-- =====================================================\n     STEP 2 \u2014 PATIENT\n     ===================================================== -->\n\n<section class=\"ga-step\" data-step=\"2\">\n\n<div class=\"ga-step-eyebrow\">Step 2<\/div>\n\n<h2>\n    Who needs medical assistance?\n<\/h2>\n\n<p class=\"ga-step-description\">\n    Tell us who the treatment is for.\n<\/p>\n\n<div class=\"ga-required-note\">\n    <strong>*<\/strong> Required\n<\/div>\n\n<div\n    class=\"ga-option-group\"\n    id=\"groupPatient\">\n\n<div class=\"ga-options\">\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"patient_type\"\n               id=\"gaPatientSelf\"\n               value=\"Myself\">\n        <label for=\"gaPatientSelf\">\n            <span class=\"ga-radio\"><\/span>\n            Myself\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"patient_type\"\n               id=\"gaPatientChild\"\n               value=\"My child\">\n        <label for=\"gaPatientChild\">\n            <span class=\"ga-radio\"><\/span>\n            My child\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"patient_type\"\n               id=\"gaPatientSpouse\"\n               value=\"My spouse\">\n        <label for=\"gaPatientSpouse\">\n            <span class=\"ga-radio\"><\/span>\n            My spouse\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"patient_type\"\n               id=\"gaPatientFamily\"\n               value=\"Another family member\">\n        <label for=\"gaPatientFamily\">\n            <span class=\"ga-radio\"><\/span>\n            Another family member\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"patient_type\"\n               id=\"gaPatientOther\"\n               value=\"Someone else\">\n        <label for=\"gaPatientOther\">\n            <span class=\"ga-radio\"><\/span>\n            Someone else\n        <\/label>\n    <\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div\n    class=\"ga-conditional\"\n    id=\"gaAgeBox\">\n\n    <div class=\"ga-field\">\n\n        <label for=\"gaPatientAge\">\n            Patient&#8217;s age <span class=\"ga-required\">*<\/span>\n        <\/label>\n\n        <select\n            class=\"ga-select\"\n            id=\"gaPatientAge\">\n\n            <option value=\"\">\n                Select age range\n            <\/option>\n\n            <option>Under 18<\/option>\n            <option>18\u201330<\/option>\n            <option>31\u201350<\/option>\n            <option>51\u201365<\/option>\n            <option>Over 65<\/option>\n\n        <\/select>\n\n        <div\n            class=\"ga-error-message\"\n            id=\"errorPatientAge\">\n            Please select the patient&#8217;s age range.\n        <\/div>\n\n    <\/div>\n\n<\/div>\n\n\n<div class=\"ga-actions\">\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-secondary\"\n    data-ga-action=\"back\">\n    \u2190 Back\n<\/button>\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-primary\"\n    data-ga-action=\"next\">\n    Continue \u2192\n<\/button>\n\n<\/div>\n\n<\/section>\n\n\n<!-- =====================================================\n     STEP 3 \u2014 MEDICAL SITUATION\n     ===================================================== -->\n\n<section class=\"ga-step\" data-step=\"3\">\n\n<div class=\"ga-step-eyebrow\">Step 3<\/div>\n\n<h2>\n    Tell us about the medical situation\n<\/h2>\n\n<p class=\"ga-step-description\">\n    We only ask for information that helps us understand\n    the type of medical assistance being requested.\n<\/p>\n\n<div class=\"ga-required-note\">\n    <strong>*<\/strong> Required &nbsp;&nbsp; \u00b7 &nbsp;&nbsp;\n    Fields marked Optional do not need to be completed.\n<\/div>\n\n\n<div class=\"ga-field\">\n\n<label for=\"gaMedicalType\">\n    What type of medical assistance are you seeking?\n    <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<select\n    class=\"ga-select\"\n    id=\"gaMedicalType\">\n\n<option value=\"\">Select an option<\/option>\n\n<option>Diagnosis \/ medical consultation<\/option>\n<option>Surgery<\/option>\n<option>Cancer treatment<\/option>\n<option>Cardiology<\/option>\n<option>Orthopedics<\/option>\n<option>Neurology \/ neurosurgery<\/option>\n<option>Fertility \/ reproductive treatment<\/option>\n<option>Kidney treatment<\/option>\n<option>Full body check-up<\/option>\n<option>Gastroenterology<\/option>\n<option>Other<\/option>\n\n<\/select>\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorMedicalType\">\n    Please select the type of medical assistance.\n<\/div>\n\n<\/div>\n\n\n<div\n    class=\"ga-conditional\"\n    id=\"gaMedicalOtherBox\">\n\n<div class=\"ga-field\">\n\n<label for=\"gaMedicalOther\">\n    Please specify <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<input\n    type=\"text\"\n    class=\"ga-input\"\n    id=\"gaMedicalOther\"\n    placeholder=\"Please specify\">\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorMedicalOther\">\n    Please specify the type of medical assistance.\n<\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-field\">\n\n<label>\n    Have you already received a medical diagnosis?\n    <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<div\n    class=\"ga-option-group\"\n    id=\"groupDiagnosis\">\n\n<div class=\"ga-options\">\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"diagnosis\"\n               id=\"gaDiagnosisYes\"\n               value=\"Yes\">\n        <label for=\"gaDiagnosisYes\">\n            <span class=\"ga-radio\"><\/span>\n            Yes\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"diagnosis\"\n               id=\"gaDiagnosisNo\"\n               value=\"No\">\n        <label for=\"gaDiagnosisNo\">\n            <span class=\"ga-radio\"><\/span>\n            No\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"diagnosis\"\n               id=\"gaDiagnosisUnsure\"\n               value=\"Not sure\">\n        <label for=\"gaDiagnosisUnsure\">\n            <span class=\"ga-radio\"><\/span>\n            I&#8217;m not sure\n        <\/label>\n    <\/div>\n\n<\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div\n    class=\"ga-conditional\"\n    id=\"gaDiagnosisYesBox\">\n\n<div class=\"ga-field\">\n\n<label for=\"gaDiagnosisText\">\n    What is the diagnosis?\n    <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<textarea\n    class=\"ga-textarea\"\n    id=\"gaDiagnosisText\"\n    placeholder=\"Briefly describe the diagnosis...\"><\/textarea>\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorDiagnosisText\">\n    Please briefly describe the diagnosis.\n<\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div\n    class=\"ga-conditional\"\n    id=\"gaDiagnosisNoBox\">\n\n<div class=\"ga-field\">\n\n<label for=\"gaSymptomsText\">\n    Briefly describe the medical problem\n    <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<textarea\n    class=\"ga-textarea\"\n    id=\"gaSymptomsText\"\n    placeholder=\"Tell us briefly about the patient's medical situation or symptoms...\"><\/textarea>\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorSymptomsText\">\n    Please briefly describe the medical problem.\n<\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div\n    class=\"ga-conditional\"\n    id=\"gaDiagnosisUnsureBox\">\n\n<div class=\"ga-field\">\n\n<label for=\"gaUnsureText\">\n    Tell us briefly what you know\n    <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<textarea\n    class=\"ga-textarea\"\n    id=\"gaUnsureText\"\n    placeholder=\"Simply describe what you know about the situation...\"><\/textarea>\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorUnsureText\">\n    Please provide a brief description.\n<\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-actions\">\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-secondary\"\n    data-ga-action=\"back\">\n    \u2190 Back\n<\/button>\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-primary\"\n    data-ga-action=\"next\">\n    Continue \u2192\n<\/button>\n\n<\/div>\n\n<\/section>\n\n\n<!-- =====================================================\n     STEP 4 \u2014 PREVIOUS TREATMENT\n     ===================================================== -->\n\n<section class=\"ga-step\" data-step=\"4\">\n\n<div class=\"ga-step-eyebrow\">Step 4<\/div>\n\n<h2>\n    Has the patient already received treatment?\n<\/h2>\n\n<p class=\"ga-step-description\">\n    This helps us understand whether the request concerns\n    new treatment, continuation of care or another opinion.\n<\/p>\n\n<div class=\"ga-required-note\">\n    <strong>*<\/strong> Required\n<\/div>\n\n<div\n    class=\"ga-option-group\"\n    id=\"groupTreatment\">\n\n<div class=\"ga-options\">\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"previous_treatment\"\n               id=\"gaTreatmentYes\"\n               value=\"Yes\">\n        <label for=\"gaTreatmentYes\">\n            <span class=\"ga-radio\"><\/span>\n            Yes\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"previous_treatment\"\n               id=\"gaTreatmentNo\"\n               value=\"No\">\n        <label for=\"gaTreatmentNo\">\n            <span class=\"ga-radio\"><\/span>\n            No\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"previous_treatment\"\n               id=\"gaTreatmentCurrent\"\n               value=\"Currently receiving treatment\">\n        <label for=\"gaTreatmentCurrent\">\n            <span class=\"ga-radio\"><\/span>\n            Currently receiving treatment\n        <\/label>\n    <\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div\n    class=\"ga-conditional\"\n    id=\"gaPreviousTreatmentBox\">\n\n<div class=\"ga-field\">\n\n<label for=\"gaTreatmentLocation\">\n    Where was the treatment received?\n    <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<input\n    type=\"text\"\n    class=\"ga-input\"\n    id=\"gaTreatmentLocation\"\n    placeholder=\"Hospital, clinic or country\">\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorTreatmentLocation\">\n    Please enter where the treatment was received.\n<\/div>\n\n<\/div>\n\n<div class=\"ga-field\">\n\n<label for=\"gaTreatmentDetails\">\n    What treatment was provided?\n    <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<select\n    class=\"ga-select\"\n    id=\"gaTreatmentDetails\">\n\n    <option value=\"\">\n        Please select the treatment\n    <\/option>\n\n    <option value=\"Medication \/ drug treatment\">\n        Medication \/ drug treatment\n    <\/option>\n\n    <option value=\"Surgery\">\n        Surgery\n    <\/option>\n\n    <option value=\"Chemotherapy\">\n        Chemotherapy\n    <\/option>\n\n    <option value=\"Radiotherapy\">\n        Radiotherapy\n    <\/option>\n\n    <option value=\"Physiotherapy \/ rehabilitation\">\n        Physiotherapy \/ rehabilitation\n    <\/option>\n\n    <option value=\"Dialysis\">\n        Dialysis\n    <\/option>\n\n    <option value=\"Fertility \/ reproductive treatment\">\n        Fertility \/ reproductive treatment\n    <\/option>\n\n    <option value=\"Diagnostic \/ medical tests\">\n        Diagnostic \/ medical tests\n    <\/option>\n\n    <option value=\"Other\">\n        Other\n    <\/option>\n\n<\/select>\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorTreatmentDetails\">\n    Please select the treatment provided.\n<\/div>\n\n<\/div>\n\n<div\n    class=\"ga-field ga-conditional\"\n    id=\"gaTreatmentOtherBox\">\n\n<label for=\"gaTreatmentOther\">\n    Please specify the treatment\n    <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<input\n    type=\"text\"\n    class=\"ga-input\"\n    id=\"gaTreatmentOther\"\n    placeholder=\"Enter the treatment\">\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorTreatmentOther\">\n    Please specify the treatment.\n<\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-actions\">\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-secondary\"\n    data-ga-action=\"back\">\n    \u2190 Back\n<\/button>\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-primary\"\n    data-ga-action=\"next\">\n    Continue \u2192\n<\/button>\n\n<\/div>\n\n<\/section>\n\n\n<!-- =====================================================\n     STEP 5 \u2014 DOCUMENTS\n     ===================================================== -->\n\n<section class=\"ga-step\" data-step=\"5\">\n\n<div class=\"ga-step-eyebrow\">Step 5<\/div>\n\n<h2>\n    Do you have medical documents?\n<\/h2>\n\n<p class=\"ga-step-description\">\n    Medical reports can help us understand the case.\n    You can continue even if you do not have documents.\n<\/p>\n\n<div class=\"ga-required-note\">\n    <strong>*<\/strong> Required\n<\/div>\n\n<div\n    class=\"ga-option-group\"\n    id=\"groupDocuments\">\n\n<div class=\"ga-options\">\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"documents\"\n               id=\"gaDocumentsYes\"\n               value=\"Yes\">\n        <label for=\"gaDocumentsYes\">\n            <span class=\"ga-radio\"><\/span>\n            Yes, I have medical documents\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"documents\"\n               id=\"gaDocumentsSome\"\n               value=\"Some\">\n        <label for=\"gaDocumentsSome\">\n            <span class=\"ga-radio\"><\/span>\n            I have some documents\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"documents\"\n               id=\"gaDocumentsNo\"\n               value=\"No\">\n        <label for=\"gaDocumentsNo\">\n            <span class=\"ga-radio\"><\/span>\n            No documents available\n        <\/label>\n    <\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div\n    class=\"ga-conditional\"\n    id=\"gaDocumentsEmailBox\">\n\n<div class=\"ga-info\">\n\n<div class=\"ga-info-mark\">\n    i\n<\/div>\n\n<div class=\"ga-info-text\">\n    <strong>You can send your medical documents after submitting this evaluation.<\/strong><br>\n    Please email your medical reports, test results, scans, prescriptions,\n    or other relevant documents to\n    <strong>contact@gloryassistance.com<\/strong>.<br><br>\n    <strong>After you submit the evaluation, you will receive an Evaluation Reference Number\n    (for example, GA-2026-0006).<\/strong> Please include that reference number in your email\n    so we can match your documents to your evaluation.\n<\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-info\">\n\n<div class=\"ga-info-mark\">i<\/div>\n\n<div class=\"ga-info-text\">\n    You can continue without documents.\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-actions\">\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-secondary\"\n    data-ga-action=\"back\">\n    \u2190 Back\n<\/button>\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-primary\"\n    data-ga-action=\"next\">\n    Continue \u2192\n<\/button>\n\n<\/div>\n\n<\/section>\n\n\n<!-- =====================================================\n     STEP 6 \u2014 HOSPITAL COUNTRY \/ DESTINATION\n     ===================================================== -->\n\n<section class=\"ga-step\" data-step=\"6\">\n\n<div class=\"ga-step-eyebrow\">Step 6<\/div>\n\n<h2>\n    Where would you like to receive treatment?\n<\/h2>\n\n<p class=\"ga-step-description\">\n    Tell us your preferred treatment destination. If you are\n    considering another country, choose it from the list.\n<\/p>\n\n<div class=\"ga-required-note\">\n    <strong>*<\/strong> Required\n<\/div>\n\n\n<div class=\"ga-field\">\n\n<label for=\"gaHospitalCountry\">\n    Hospital Country <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<select\n    class=\"ga-select\"\n    id=\"gaHospitalCountry\">\n\n<option value=\"\">\n    Select country\n<\/option>\n\n<option value=\"India\">\n    India\n<\/option>\n\n<option value=\"Spain\">\n    Spain\n<\/option>\n\n<option value=\"Other country\">\n    Other country\n<\/option>\n\n<\/select>\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorHospitalCountry\">\n    Please select a treatment destination.\n<\/div>\n\n<\/div>\n\n\n<div\n    class=\"ga-conditional\"\n    id=\"gaOtherHospitalCountryBox\">\n\n<div class=\"ga-field\">\n\n<label for=\"gaOtherHospitalCountry\">\n    Please select the country <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<select\n    class=\"ga-select\"\n    id=\"gaOtherHospitalCountry\">\n\n<option value=\"\">\n    Select another country\n<\/option>\n\n<option>Belgium<\/option>\n<option>France<\/option>\n<option>Germany<\/option>\n<option>Italy<\/option>\n<option>Netherlands<\/option>\n<option>Portugal<\/option>\n<option>Turkey<\/option>\n<option>United Arab Emirates<\/option>\n<option>South Africa<\/option>\n<option>Egypt<\/option>\n<option>Morocco<\/option>\n<option>Tunisia<\/option>\n<option>Kenya<\/option>\n<option>Rwanda<\/option>\n<option>Uganda<\/option>\n<option>United Kingdom<\/option>\n<option>United States<\/option>\n<option>Canada<\/option>\n<option>Australia<\/option>\n<option>China<\/option>\n<option>Thailand<\/option>\n<option>Malaysia<\/option>\n<option>South Korea<\/option>\n<option>Other<\/option>\n\n<\/select>\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorOtherHospitalCountry\">\n    Please select the country.\n<\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div\n    class=\"ga-conditional\"\n    id=\"gaHospitalCountryOtherBox\">\n\n<div class=\"ga-field\">\n\n<label for=\"gaHospitalCountryOther\">\n    Please specify <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<input\n    type=\"text\"\n    class=\"ga-input\"\n    id=\"gaHospitalCountryOther\"\n    placeholder=\"Enter the country\">\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorHospitalCountryOther\">\n    Please specify the country.\n<\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-field\">\n\n<label>\n    Do you already have a hospital or doctor in mind?\n    <span class=\"ga-optional\">Optional<\/span>\n<\/label>\n\n<div class=\"ga-options\">\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"hospital_known\"\n               id=\"gaHospitalKnownYes\"\n               value=\"Yes\">\n        <label for=\"gaHospitalKnownYes\">\n            <span class=\"ga-radio\"><\/span>\n            Yes\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"hospital_known\"\n               id=\"gaHospitalKnownNo\"\n               value=\"No\">\n        <label for=\"gaHospitalKnownNo\">\n            <span class=\"ga-radio\"><\/span>\n            No, I need assistance\n        <\/label>\n    <\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div\n    class=\"ga-conditional\"\n    id=\"gaHospitalDetailsBox\">\n\n<div class=\"ga-field\">\n\n<label for=\"gaHospitalDetails\">\n    Hospital or doctor name\n    <span class=\"ga-optional\">Optional<\/span>\n<\/label>\n\n<input\n    type=\"text\"\n    class=\"ga-input\"\n    id=\"gaHospitalDetails\"\n    placeholder=\"Hospital, clinic or doctor\">\n\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-actions\">\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-secondary\"\n    data-ga-action=\"back\">\n    \u2190 Back\n<\/button>\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-primary\"\n    data-ga-action=\"next\">\n    Continue \u2192\n<\/button>\n\n<\/div>\n\n<\/section>\n\n\n<!-- =====================================================\n     STEP 7 \u2014 URGENCY\n     ===================================================== -->\n\n<section class=\"ga-step\" data-step=\"7\">\n\n<div class=\"ga-step-eyebrow\">Step 7<\/div>\n\n<h2>\n    How soon do you need assistance?\n<\/h2>\n\n<p class=\"ga-step-description\">\n    This helps our team understand the timing of your\n    treatment project.\n<\/p>\n\n<div class=\"ga-required-note\">\n    <strong>*<\/strong> Required\n<\/div>\n\n<div\n    class=\"ga-option-group\"\n    id=\"groupUrgency\">\n\n<div class=\"ga-options\">\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"urgency\"\n               id=\"gaUrgencyNow\"\n               value=\"As soon as possible\">\n        <label for=\"gaUrgencyNow\">\n            <span class=\"ga-radio\"><\/span>\n            As soon as possible\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"urgency\"\n               id=\"gaUrgencyWeeks\"\n               value=\"Within the next few weeks\">\n        <label for=\"gaUrgencyWeeks\">\n            <span class=\"ga-radio\"><\/span>\n            Within the next few weeks\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"urgency\"\n               id=\"gaUrgencyMonths\"\n               value=\"Within 1\u20133 months\">\n        <label for=\"gaUrgencyMonths\">\n            <span class=\"ga-radio\"><\/span>\n            Within 1\u20133 months\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"urgency\"\n               id=\"gaUrgencyPlanning\"\n               value=\"Planning for the future\">\n        <label for=\"gaUrgencyPlanning\">\n            <span class=\"ga-radio\"><\/span>\n            I&#8217;m only planning for now\n        <\/label>\n    <\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-actions\">\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-secondary\"\n    data-ga-action=\"back\">\n    \u2190 Back\n<\/button>\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-primary\"\n    data-ga-action=\"next\">\n    Continue \u2192\n<\/button>\n\n<\/div>\n\n<\/section>\n\n\n<!-- =====================================================\n     STEP 8 \u2014 VISA INTRO\n     ===================================================== -->\n\n<section class=\"ga-step\" data-step=\"8\">\n\n<div class=\"ga-step-eyebrow\">\n    Visa Assistance\n<\/div>\n\n<h2>\n    Let&#8217;s understand your travel and visa needs\n<\/h2>\n\n<p class=\"ga-step-description\">\n    Because you selected medical treatment together with\n    visa assistance, we need a few additional details about\n    your international travel history and visa situation.\n<\/p>\n\n<div class=\"ga-section-note\">\n    These questions are only shown because you requested\n    medical treatment + visa assistance.\n<\/div>\n\n<div class=\"ga-actions\">\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-secondary\"\n    data-ga-action=\"back\">\n    \u2190 Back\n<\/button>\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-primary\"\n    data-ga-action=\"next\">\n    Continue to Visa Questions \u2192\n<\/button>\n\n<\/div>\n\n<\/section>\n\n\n<!-- =====================================================\n     STEP 9 \u2014 VISA TRAVEL HISTORY\n     ===================================================== -->\n\n<section class=\"ga-step\" data-step=\"9\">\n\n<div class=\"ga-step-eyebrow\">\n    Visa \u2014 Step 1\n<\/div>\n\n<h2>\n    Have you travelled internationally before?\n<\/h2>\n\n<p class=\"ga-step-description\">\n    This helps us understand your previous international\n    travel experience.\n<\/p>\n\n<div class=\"ga-required-note\">\n    <strong>*<\/strong> Required\n<\/div>\n\n<div\n    class=\"ga-option-group\"\n    id=\"groupInternationalTravel\">\n\n<div class=\"ga-options\">\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"international_travel\"\n               id=\"gaTravelInternationalYes\"\n               value=\"Yes\">\n        <label for=\"gaTravelInternationalYes\">\n            <span class=\"ga-radio\"><\/span>\n            Yes\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"international_travel\"\n               id=\"gaTravelInternationalNo\"\n               value=\"No\">\n        <label for=\"gaTravelInternationalNo\">\n            <span class=\"ga-radio\"><\/span>\n            No\n        <\/label>\n    <\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div\n    class=\"ga-conditional\"\n    id=\"gaTravelCountriesBox\">\n\n<div class=\"ga-field\">\n\n<label>\n    Which countries have you travelled to?\n    <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<p style=\"margin:-2px 0 12px;color:#78857f;font-size:12px;line-height:1.5;\">\n    You can select more than one country.\n<\/p>\n\n<div class=\"ga-country-picker\">\n\n<select\n    class=\"ga-select\"\n    id=\"gaTravelCountrySelect\">\n\n<option value=\"\">\n    Select a country\n<\/option>\n\n<option>Belgium<\/option>\n<option>Canada<\/option>\n<option>China<\/option>\n<option>Egypt<\/option>\n<option>France<\/option>\n<option>Germany<\/option>\n<option>India<\/option>\n<option>Italy<\/option>\n<option>Kenya<\/option>\n<option>Malaysia<\/option>\n<option>Morocco<\/option>\n<option>Netherlands<\/option>\n<option>Portugal<\/option>\n<option>Rwanda<\/option>\n<option>South Africa<\/option>\n<option>Spain<\/option>\n<option>Tanzania<\/option>\n<option>Thailand<\/option>\n<option>Turkey<\/option>\n<option>Uganda<\/option>\n<option>United Arab Emirates<\/option>\n<option>United Kingdom<\/option>\n<option>United States<\/option>\n<option>Other<\/option>\n\n<\/select>\n\n<button\n    type=\"button\"\n    class=\"ga-add-country\"\n    data-ga-action=\"add-travel\">\n    + Add\n<\/button>\n\n<\/div>\n\n<div\n    class=\"ga-selected-countries\"\n    id=\"gaSelectedTravelCountries\">\n<\/div>\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorTravelCountries\">\n    Please select at least one country.\n<\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-actions\">\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-secondary\"\n    data-ga-action=\"back\">\n    \u2190 Back\n<\/button>\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-primary\"\n    data-ga-action=\"next\">\n    Continue \u2192\n<\/button>\n\n<\/div>\n\n<\/section>\n\n\n<!-- =====================================================\n     STEP 10 \u2014 VISA REFUSAL\n     ===================================================== -->\n\n<section class=\"ga-step\" data-step=\"10\">\n\n<div class=\"ga-step-eyebrow\">\n    Visa \u2014 Step 2\n<\/div>\n\n<h2>\n    Have you previously had a visa refused or rejected?\n<\/h2>\n\n<p class=\"ga-step-description\">\n    Please answer honestly. This information helps us\n    understand your previous visa history and provide\n    more appropriate guidance.\n<\/p>\n\n<div class=\"ga-required-note\">\n    <strong>*<\/strong> Required\n<\/div>\n\n<div\n    class=\"ga-option-group\"\n    id=\"groupVisaRefusal\">\n\n<div class=\"ga-options\">\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"visa_refusal\"\n               id=\"gaRefusalYes\"\n               value=\"Yes\">\n        <label for=\"gaRefusalYes\">\n            <span class=\"ga-radio\"><\/span>\n            Yes\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"visa_refusal\"\n               id=\"gaRefusalNo\"\n               value=\"No\">\n        <label for=\"gaRefusalNo\">\n            <span class=\"ga-radio\"><\/span>\n            No\n        <\/label>\n    <\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div\n    class=\"ga-conditional\"\n    id=\"gaRefusalDetails\">\n\n<div class=\"ga-field\">\n\n<label for=\"gaRefusalCountry\">\n    Which country refused your visa?\n    <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<select\n    class=\"ga-select\"\n    id=\"gaRefusalCountry\">\n\n<option value=\"\">\n    Select country\n<\/option>\n\n<option>Belgium<\/option>\n<option>Canada<\/option>\n<option>China<\/option>\n<option>France<\/option>\n<option>Germany<\/option>\n<option>India<\/option>\n<option>Italy<\/option>\n<option>Netherlands<\/option>\n<option>Portugal<\/option>\n<option>South Africa<\/option>\n<option>Spain<\/option>\n<option>Turkey<\/option>\n<option>United Arab Emirates<\/option>\n<option>United Kingdom<\/option>\n<option>United States<\/option>\n<option>Other<\/option>\n\n<\/select>\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorRefusalCountry\">\n    Please select the country.\n<\/div>\n\n<\/div>\n\n\n<div\n    class=\"ga-conditional\"\n    id=\"gaRefusalOtherCountryBox\">\n\n<div class=\"ga-field\">\n\n<label for=\"gaRefusalOtherCountry\">\n    Please specify <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<input\n    type=\"text\"\n    class=\"ga-input\"\n    id=\"gaRefusalOtherCountry\"\n    placeholder=\"Enter country\">\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorRefusalOtherCountry\">\n    Please specify the country.\n<\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-field\">\n\n<label for=\"gaRefusalYear\">\n    When was the refusal?\n    <span class=\"ga-optional\">Optional<\/span>\n<\/label>\n\n<select\n    class=\"ga-select\"\n    id=\"gaRefusalYear\">\n\n<option value=\"\">\n    Select year\n<\/option>\n\n<option>2026<\/option>\n<option>2025<\/option>\n<option>2024<\/option>\n<option>2023<\/option>\n<option>2022<\/option>\n<option>2021<\/option>\n<option>2020<\/option>\n<option>2019<\/option>\n<option>2018<\/option>\n<option>2017<\/option>\n<option>2016<\/option>\n<option>Before 2016<\/option>\n<option>I don&#8217;t remember<\/option>\n\n<\/select>\n\n<\/div>\n\n\n<div class=\"ga-field\">\n\n<label for=\"gaRefusalReason\">\n    Do you know the reason for the refusal?\n    <span class=\"ga-optional\">Optional<\/span>\n<\/label>\n\n<textarea\n    class=\"ga-textarea\"\n    id=\"gaRefusalReason\"\n    placeholder=\"If you know the reason, briefly describe it...\"><\/textarea>\n\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-actions\">\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-secondary\"\n    data-ga-action=\"back\">\n    \u2190 Back\n<\/button>\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-primary\"\n    data-ga-action=\"next\">\n    Continue \u2192\n<\/button>\n\n<\/div>\n\n<\/section>\n\n\n<!-- =====================================================\n     STEP 11 \u2014 VISA DESTINATION\n     ===================================================== -->\n\n<section class=\"ga-step\" data-step=\"11\">\n\n<div class=\"ga-step-eyebrow\">\n    Visa \u2014 Step 3\n<\/div>\n\n<h2>\n    Which country do you intend to travel to?\n<\/h2>\n\n<p class=\"ga-step-description\">\n    Tell us the country where the medical treatment will\n    take place.\n<\/p>\n\n<div class=\"ga-required-note\">\n    <strong>*<\/strong> Required\n<\/div>\n\n\n<div class=\"ga-field\">\n\n<label for=\"gaVisaCountry\">\n    Intended destination <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<select\n    class=\"ga-select\"\n    id=\"gaVisaCountry\">\n\n<option value=\"\">\n    Select country\n<\/option>\n\n<option>India<\/option>\n<option>Spain<\/option>\n<option>Turkey<\/option>\n<option>United Arab Emirates<\/option>\n<option>South Africa<\/option>\n<option>United Kingdom<\/option>\n<option>United States<\/option>\n<option>Canada<\/option>\n<option>France<\/option>\n<option>Germany<\/option>\n<option>Other<\/option>\n\n<\/select>\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorVisaCountry\">\n    Please select your intended destination.\n<\/div>\n\n<\/div>\n\n\n<div\n    class=\"ga-conditional\"\n    id=\"gaVisaOtherCountryBox\">\n\n<div class=\"ga-field\">\n\n<label for=\"gaVisaOtherCountry\">\n    Please specify <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<input\n    type=\"text\"\n    class=\"ga-input\"\n    id=\"gaVisaOtherCountry\"\n    placeholder=\"Enter country\">\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorVisaOtherCountry\">\n    Please specify the country.\n<\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-field\">\n\n<label>\n    What type of visa assistance do you need?\n    <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<div\n    class=\"ga-option-group\"\n    id=\"groupVisaType\">\n\n<div class=\"ga-options\">\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"visa_type\"\n               id=\"gaVisaMedical\"\n               value=\"Medical visa\">\n        <label for=\"gaVisaMedical\">\n            <span class=\"ga-radio\"><\/span>\n            Medical visa\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"visa_type\"\n               id=\"gaVisaNotSure\"\n               value=\"Not sure\">\n        <label for=\"gaVisaNotSure\">\n            <span class=\"ga-radio\"><\/span>\n            I&#8217;m not sure\n        <\/label>\n    <\/div>\n\n<\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-actions\">\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-secondary\"\n    data-ga-action=\"back\">\n    \u2190 Back\n<\/button>\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-primary\"\n    data-ga-action=\"next\">\n    Continue \u2192\n<\/button>\n\n<\/div>\n\n<\/section>\n\n\n<!-- =====================================================\n     STEP 12 \u2014 PASSPORT\n     ===================================================== -->\n\n<section class=\"ga-step\" data-step=\"12\">\n\n<div class=\"ga-step-eyebrow\">\n    Visa \u2014 Step 4\n<\/div>\n\n<h2>\n    Do you currently have a valid passport?\n<\/h2>\n\n<p class=\"ga-step-description\">\n    A valid passport is generally required for international\n    travel and visa processing.\n<\/p>\n\n<div class=\"ga-required-note\">\n    <strong>*<\/strong> Required\n<\/div>\n\n<div\n    class=\"ga-option-group\"\n    id=\"groupPassport\">\n\n<div class=\"ga-options\">\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"passport_status\"\n               id=\"gaPassportYes\"\n               value=\"Yes\">\n        <label for=\"gaPassportYes\">\n            <span class=\"ga-radio\"><\/span>\n            Yes\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"passport_status\"\n               id=\"gaPassportExpired\"\n               value=\"Expired\">\n        <label for=\"gaPassportExpired\">\n            <span class=\"ga-radio\"><\/span>\n            Yes, but it is expired\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"passport_status\"\n               id=\"gaPassportNo\"\n               value=\"No\">\n        <label for=\"gaPassportNo\">\n            <span class=\"ga-radio\"><\/span>\n            No, I don&#8217;t have one\n        <\/label>\n    <\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-actions\">\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-secondary\"\n    data-ga-action=\"back\">\n    \u2190 Back\n<\/button>\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-primary\"\n    data-ga-action=\"next\">\n    Continue \u2192\n<\/button>\n\n<\/div>\n\n<\/section>\n\n\n<!-- =====================================================\n     STEP 13 \u2014 TRAVEL TIMING\n     ===================================================== -->\n\n<section class=\"ga-step\" data-step=\"13\">\n\n<div class=\"ga-step-eyebrow\">\n    Visa \u2014 Step 5\n<\/div>\n\n<h2>\n    When would you like to travel?\n<\/h2>\n\n<p class=\"ga-step-description\">\n    This helps us understand the timing of your medical\n    treatment and visa process.\n<\/p>\n\n<div class=\"ga-required-note\">\n    <strong>*<\/strong> Required\n<\/div>\n\n<div\n    class=\"ga-option-group\"\n    id=\"groupTravelTiming\">\n\n<div class=\"ga-options\">\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"travel_timing\"\n               id=\"gaTravelSoon\"\n               value=\"As soon as possible\">\n        <label for=\"gaTravelSoon\">\n            <span class=\"ga-radio\"><\/span>\n            As soon as possible\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"travel_timing\"\n               id=\"gaTravelWeeks\"\n               value=\"Within the next few weeks\">\n        <label for=\"gaTravelWeeks\">\n            <span class=\"ga-radio\"><\/span>\n            Within the next few weeks\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"travel_timing\"\n               id=\"gaTravelMonths\"\n               value=\"Within 1\u20133 months\">\n        <label for=\"gaTravelMonths\">\n            <span class=\"ga-radio\"><\/span>\n            Within 1\u20133 months\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"travel_timing\"\n               id=\"gaTravelPlanning\"\n               value=\"Planning for later\">\n        <label for=\"gaTravelPlanning\">\n            <span class=\"ga-radio\"><\/span>\n            Planning for later\n        <\/label>\n    <\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-actions\">\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-secondary\"\n    data-ga-action=\"back\">\n    \u2190 Back\n<\/button>\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-primary\"\n    data-ga-action=\"next\">\n    Continue \u2192\n<\/button>\n\n<\/div>\n\n<\/section>\n\n\n<!-- =====================================================\n     STEP 14 \u2014 CONTACT\n     ===================================================== -->\n\n<section class=\"ga-step\" data-step=\"14\">\n\n<div class=\"ga-step-eyebrow\">\n    Final Information\n<\/div>\n\n<h2>\n    Tell us how we can contact you\n<\/h2>\n\n<p class=\"ga-step-description\">\n    We need a few details so our team can follow up regarding\n    your request.\n<\/p>\n\n<div class=\"ga-required-note\">\n    <strong>*<\/strong> Required &nbsp;&nbsp; \u00b7 &nbsp;&nbsp;\n    Optional fields are clearly marked.\n<\/div>\n\n\n<div class=\"ga-field-grid\">\n\n<div class=\"ga-field\">\n\n<label for=\"gaFullName\">\n    Full name <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<input\n    type=\"text\"\n    class=\"ga-input\"\n    id=\"gaFullName\"\n    placeholder=\"Your full name\">\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorFullName\">\n    Please enter your full name.\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-field\">\n\n<label for=\"gaCountry\">\n    Country of residence <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<input\n    type=\"text\"\n    class=\"ga-input\"\n    id=\"gaCountry\"\n    placeholder=\"Country\">\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorCountry\">\n    Please enter your country of residence.\n<\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-field-grid\">\n\n<div class=\"ga-field\">\n\n<label for=\"gaCity\">\n    City <span class=\"ga-optional\">Optional<\/span>\n<\/label>\n\n<input\n    type=\"text\"\n    class=\"ga-input\"\n    id=\"gaCity\"\n    placeholder=\"City\">\n\n<\/div>\n\n\n<div class=\"ga-field\">\n\n<label for=\"gaPhone\">\n    Phone \/ WhatsApp <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<input\n    type=\"text\"\n    class=\"ga-input\"\n    id=\"gaPhone\"\n    placeholder=\"Phone or WhatsApp number\">\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorPhone\">\n    Please enter your phone or WhatsApp number.\n<\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-field\">\n\n<label for=\"gaEmail\">\n    Email address <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<input\n    type=\"email\"\n    class=\"ga-input\"\n    id=\"gaEmail\"\n    placeholder=\"your@email.com\">\n\n<div\n    class=\"ga-error-message\"\n    id=\"errorEmail\">\n    Please enter a valid email address.\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-field\">\n\n<label>\n    Who should we contact about this request?\n    <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<div\n    class=\"ga-option-group\"\n    id=\"groupContactPerson\">\n\n<div class=\"ga-options\">\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"contact_person\"\n               id=\"gaContactPatient\"\n               value=\"The patient\">\n        <label for=\"gaContactPatient\">\n            <span class=\"ga-radio\"><\/span>\n            The patient\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"contact_person\"\n               id=\"gaContactFamily\"\n               value=\"A family member\">\n        <label for=\"gaContactFamily\">\n            <span class=\"ga-radio\"><\/span>\n            A family member\n        <\/label>\n    <\/div>\n\n    <div class=\"ga-option\">\n        <input type=\"radio\"\n               name=\"contact_person\"\n               id=\"gaContactRepresentative\"\n               value=\"Another representative\">\n        <label for=\"gaContactRepresentative\">\n            <span class=\"ga-radio\"><\/span>\n            Another representative\n        <\/label>\n    <\/div>\n\n<\/div>\n\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-actions\">\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-secondary\"\n    data-ga-action=\"back\">\n    \u2190 Back\n<\/button>\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-primary\"\n    data-ga-action=\"next\">\n    Continue \u2192\n<\/button>\n\n<\/div>\n\n<\/section>\n\n\n<!-- =====================================================\n     STEP 15 \u2014 ADDITIONAL INFORMATION\n     ===================================================== -->\n\n<section class=\"ga-step\" data-step=\"15\">\n\n<div class=\"ga-step-eyebrow\">\n    Additional Information\n<\/div>\n\n<h2>\n    Is there anything else we should know?\n<\/h2>\n\n<p class=\"ga-step-description\">\n    This is optional. 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Submission\n<\/div>\n\n<h2>\n    Please confirm your information\n<\/h2>\n\n<p class=\"ga-step-description\">\n    Before reviewing your request, please confirm the\n    following.\n<\/p>\n\n<div class=\"ga-required-note\">\n    <strong>*<\/strong> Both confirmations are required\n<\/div>\n\n\n<div\n    class=\"ga-consent-box\"\n    id=\"gaConsentBox\">\n\n<div class=\"ga-consent-item\">\n\n<input\n    type=\"checkbox\"\n    id=\"gaConsentAccuracy\">\n\n<label for=\"gaConsentAccuracy\">\n    I confirm that the information I have provided is\n    accurate to the best of my knowledge.\n    <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<\/div>\n\n\n<div class=\"ga-consent-item\">\n\n<input\n    type=\"checkbox\"\n    id=\"gaConsentProcessing\">\n\n<label for=\"gaConsentProcessing\">\n    I consent to Glory Assistance processing the\n    information I have provided for the purpose of\n    evaluating and responding to my request.\n    <span class=\"ga-required\">*<\/span>\n<\/label>\n\n<\/div>\n\n<div\n    class=\"ga-consent-error\"\n    id=\"gaConsentError\">\n    Please confirm both statements before continuing.\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-info\">\n\n<div class=\"ga-info-mark\">\n    i\n<\/div>\n\n<div class=\"ga-info-text\">\n    Your information will be used to evaluate your request\n    and allow Glory Assistance to respond to you.\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-actions\">\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-secondary\"\n    data-ga-action=\"back\">\n    \u2190 Back\n<\/button>\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-primary\"\n    data-ga-action=\"next\">\n    Review Request \u2192\n<\/button>\n\n<\/div>\n\n<\/section>\n\n\n<!-- =====================================================\n     STEP 17 \u2014 REVIEW\n     ===================================================== -->\n\n<section class=\"ga-step\" data-step=\"17\">\n\n<div class=\"ga-step-eyebrow\">\n    Final Review\n<\/div>\n\n<h2>\n    Review your request\n<\/h2>\n\n<p class=\"ga-step-description\">\n    Please check the information below before submitting\n    your evaluation request.\n<\/p>\n\n<div\n    class=\"ga-review\"\n    id=\"gaReview\">\n<\/div>\n\n\n<div class=\"ga-info\">\n\n<div class=\"ga-info-mark\">\n    i\n<\/div>\n\n<div class=\"ga-info-text\">\n    You can go back and make changes before submitting.\n<\/div>\n\n<\/div>\n\n\n<div class=\"ga-actions\">\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-secondary\"\n    data-ga-action=\"back\">\n    \u2190 Back\n<\/button>\n\n<button\n    type=\"button\"\n    class=\"ga-btn ga-btn-primary\"\n    data-ga-action=\"submit\">\n    Submit Evaluation \u2192\n<\/button>\n\n<\/div>\n\n<\/section>\n\n\n<!-- =====================================================\n     STEP 18 \u2014 SUCCESS\n     ===================================================== -->\n\n<section class=\"ga-step\" 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