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class="row equal-height-rt-column"> <!-- Begin Content --> <div class="col-md-9 main-content"> <div id="pnlFormText"> <h1 class="page-head">Subscribe to IG Living<a href="" class="fb-share-btn" target="_blank"></a><div class="fb-share-text">share</div></h1> <h1 class="sub-head">Sign up for your FREE subscription to the only magazine dedicated to immune globulin (IG) patients and their healthcare providers.</h1> <div class="row content-head"> <div class="col-md-4"> <img src="/assets/img/image-quarter-width-advertising-demographics-1.jpg" class="image-third-width no-border img-responsive" alt=""/> </div> <div class="col-md-8"> <p>All subscriptions include unlimited digital access to IGLiving.com content, full online magazine archive, blog posts, and IG news. 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value="/wEdABVNwzXzOWWi7Ws5bqptFqxZTNr8+Dx/H+2fNfPhxgyex+tZBdiRon5d1qE03oo5TvPnNZrJCJRCHdild+n0eSCRtmg5/DdYu/yIr/XFk0CZ2/nuSvN2ujDLViqJoMSOWQdv8LdzNGbQqpt+ZfJ/ubmwQwdmH1m48FGJ7a8D8d+hEv4aTTrOBQI5tRKH9+tlQjQHSL2j4ippVRJCswHHIb1lK5rQhy0azVwqyiCqjwOP2AjQDTHydGPwTUnKvhKCKQ3DHOazRDTsbgI1quudOxd5+Jre+25xWGGCVYDcBNvAQ1Suwa0QLRIqrvZxhRCPowd2NvjHOkq5wKoqN6Aim8WGYxpWjLwgZVq7lab79DGQSNKjXsrJTKxPZH9Ja3Ww5Mx3WvPVGxzHGyu4b4yAJM+8X7JzMDb/wVJ9mJ810Q97ixKekJuqqgYBm/AZmfRxRA4whhApx1VvXxJpuaSjrabdLTmg944e9gujYDUY3qrn/Q==" /> </div> <header>Contact</header> <fieldset> <div class="row"> <section class="col col-6"> <label class="input"> <input name="txtFirstName" type="text" id="txtFirstName" name="txtFirstName" placeholder="First name *" /> <!--<input type="text" name="txtFirstName" id="txtFirstName" placeholder="First name *">--> </label> </section> <section class="col col-6"> <label class="input"> <input name="txtLastName" type="text" id="txtLastName" name="txtLastName" placeholder="Last name *" /> <!--<input type="text" name="txtLastName" id="txtLastName" placeholder="Last name *">--> </label> </section> </div> <section> <label class="input"> <input name="txtTitle" type="text" id="txtTitle" name="txtTitle" placeholder="Title" /> <!--<input type="text" name="txtTitle" id="txtTitle" placeholder="Title">--> </label> </section> <section> <label class="input"> <input name="txtOrganizationName" type="text" id="txtOrganizationName" name="txtOrganizationName" placeholder="Organization name" /> <!--<input type="text" name="txtOrganizationName" id="txtOrganizationName" placeholder="Organization name">--> </label> </section> <div class="row"> <section class="col col-4"> <label class="input"> <input name="txtPhone" id="txtPhone" type="tel" name="txtPhone" placeholder="Phone" /> <!--<input type="tel" name="txtPhone" id="txtPhone" placeholder="Phone">--> </label> </section> <section class="col col-4"> <label class="input"> <input name="txtExtension" type="text" id="txtExtension" name="txtExtension" placeholder="Extension" /> <!--<input type="text" name="txtExtension" id="txtExtension" placeholder="Extension">--> </label> </section> <section class="col col-4"> <label class="input"> <input name="txtEmail" type="text" id="txtEmail" name="txtEmail" placeholder="Email *" /> <!--<input type="text" name="txtEmail" id="txtEmail" placeholder="Email *">--> </label> </section> </div> </fieldset> <header>Address</header> <fieldset> <section> <label class="input"> <input name="txtAddress1" type="text" id="txtAddress1" name="txtAddress1" placeholder="Address *" /> <!--<input type="text" name="txtAddress1" id="txtAddress1" placeholder="Address *">--> </label> </section> <section> <label class="input"> <input name="txtAddress2" type="text" id="txtAddress2" name="txtAddress2" placeholder="Address 2" /> <!--<input type="text" name="txtAddress2" id="txtAddress2" placeholder="Address 2">--> </label> </section> <div class="row"> <section class="col col-4"> <label class="input"> <input name="txtCity" type="text" id="txtCity" name="txtCity" placeholder="City *" /> <!--<input type="text" name="txtCity" id="txtCity" placeholder="City *">--> </label> </section> <section class="col col-4"> <label class="select"> <select name="lstState" id="lstState" class="select"> <option selected="selected" value="0" disabled="">State</option> <option value="AL"> Alabama - AL </option> <option value="AK"> Alaska - AK </option> <option value="AS"> American Samoa - AS </option> <option value="AE"> APO/FPO-Africa - AE </option> <option value="AA"> APO/FPO-Americas - AA </option> <option value="AE"> APO/FPO-Canada - AE </option> <option value="AE"> APO/FPO-Europe - AE </option> <option value="AE"> APO/FPO-Middle East - AE </option> <option value="AP"> APO/FPO-Pacific - AP </option> <option value="AZ"> Arizona - AZ </option> <option value="AR"> Arkansas - AR </option> <option value="CA"> California - CA </option> <option value="CO"> Colorado - CO </option> <option value="CT"> Connecticut - CT </option> <option value="DE"> Delaware - DE </option> <option value="DC"> District of Columbia - DC </option> <option value="FM"> Federated States of Micronesia - FM </option> <option value="FL"> Florida - FL </option> <option value="GA"> Georgia - GA </option> <option value="GU"> Guam - GU </option> <option value="HI"> Hawaii - HI </option> <option value="ID"> Idaho - ID </option> <option value="IL"> Illinois - IL </option> <option value="IN"> Indiana - IN </option> <option value="IA"> Iowa - IA </option> <option value="KS"> Kansas - KS </option> <option value="KY"> Kentucky - KY </option> <option value="LA"> Louisiana - LA </option> <option value="ME"> Maine - ME </option> <option value="MH"> Marshall Islands - MH </option> <option value="MD"> Maryland - MD </option> <option value="MA"> Massachusetts - MA </option> <option value="MI"> Michigan - MI </option> <option value="FM"> Micronesia - FM </option> <option value="MN"> Minnesota - MN </option> <option value="MS"> Mississippi - MS </option> <option value="MO"> Missouri - MO </option> <option value="MT"> Montana - MT </option> <option value="NE"> Nebraska - NE </option> <option value="NV"> Nevada - NV </option> <option value="NH"> New Hampshire - NH </option> <option value="NJ"> New Jersey - NJ </option> <option value="NM"> New Mexico - NM </option> <option value="NY"> New York - NY </option> <option value="NC"> North Carolina - NC </option> <option value="ND"> North Dakota - ND </option> <option value="MP"> Northern Mariana Islands - MP </option> <option value="OH"> Ohio - OH </option> <option value="OK"> Oklahoma - OK </option> <option value="OR"> Oregon - OR </option> <option value="PW"> Palau - PW </option> <option value="PA"> Pennsylvania - PA </option> <option value="PR"> Puerto Rico - PR </option> <option value="RI"> Rhode Island - RI </option> <option value="SC"> South Carolina - SC </option> <option value="SD"> South Dakota - SD </option> <option value="TN"> Tennessee - TN </option> <option value="TX"> Texas - TX </option> <option value="UT"> Utah - UT </option> <option value="VT"> Vermont - VT </option> <option value="VI"> Virgin Islands (US) - VI </option> <option value="VA"> Virginia - VA </option> <option value="WA"> Washington - WA </option> <option value="WV"> West Virginia - WV </option> <option value="WI"> Wisconsin - WI </option> <option value="WY"> Wyoming - WY </option> </select> <i></i> </label> </section> <section class="col col-4"> <label class="input"> <input name="txtZip" type="text" id="txtZip" name="txtZip" placeholder="Zipcode *" /> <!--<input type="text" name="txtZip" id="txtZip" placeholder="Zipcode *">--> </label> </section> </div> <div class="row"> <section class="col col-6"> <label class="select"> <select name="lstCountry" id="lstCountry" class="select"> <option value="Afghanistan">Afghanistan</option> <option value="Albania">Albania</option> <option value="Algeria">Algeria</option> <option value="Andorra">Andorra</option> <option value="Angola">Angola</option> <option value="Anguilla">Anguilla</option> <option value="Antarctica">Antarctica</option> <option value="Antigua and Barbuda">Antigua and Barbuda</option> <option value="Argentina">Argentina</option> <option value="Armenia">Armenia</option> <option value="Aruba">Aruba</option> <option value="Australia">Australia</option> <option value="Austria">Austria</option> <option value="Azerbaijan">Azerbaijan</option> <option value="Bahamas">Bahamas</option> <option value="Bahrain">Bahrain</option> <option value="Bangladesh">Bangladesh</option> <option value="Barbados">Barbados</option> <option value="Belarus">Belarus</option> <option value="Belgium">Belgium</option> <option value="Belize">Belize</option> <option value="Benin">Benin</option> <option value="Bermuda">Bermuda</option> <option value="Bhutan">Bhutan</option> <option value="Bolivia">Bolivia</option> <option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option> <option value="Botswana">Botswana</option> <option value="Bouvet Island">Bouvet Island</option> <option value="Brazil">Brazil</option> <option value="Brunei Darussalam">Brunei Darussalam</option> <option value="Bulgaria">Bulgaria</option> <option value="Burkina Faso">Burkina Faso</option> <option value="Burundi">Burundi</option> <option value="Cambodia">Cambodia</option> <option value="Cameroon">Cameroon</option> <option value="Canada">Canada</option> <option value="Cape Verde">Cape Verde</option> <option value="Cayman Islands">Cayman Islands</option> <option value="Central African Republic">Central African Republic</option> <option value="Chad">Chad</option> <option value="Chile">Chile</option> <option value="China">China</option> <option value="Christmas Island">Christmas Island</option> <option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option> <option value="Colombia">Colombia</option> <option value="Comoros">Comoros</option> <option value="Congo">Congo</option> <option value="Cook Islands">Cook Islands</option> <option value="Costa Rica">Costa Rica</option> <option value="C脙麓te d'Ivoire (Ivory Coast)">Côte d'Ivoire (Ivory Coast)</option> <option value="Croatia (Hrvatska)">Croatia (Hrvatska)</option> <option value="Cuba">Cuba</option> <option value="Cyprus">Cyprus</option> <option value="Czech Republic">Czech Republic</option> <option value="Denmark">Denmark</option> <option value="Djibouti">Djibouti</option> <option value="Dominica">Dominica</option> <option value="Dominican Republic">Dominican Republic</option> <option value="East Timor">East Timor</option> <option value="Ecuador">Ecuador</option> <option value="Egypt">Egypt</option> <option value="El Salvador">El Salvador</option> <option value="Equatorial Guinea">Equatorial Guinea</option> <option value="Eritrea">Eritrea</option> <option value="Estonia">Estonia</option> <option value="Ethiopia">Ethiopia</option> <option value="Falkland Islands">Falkland Islands</option> <option value="Faroe Islands">Faroe Islands</option> <option value="Fiji">Fiji</option> <option value="Finland">Finland</option> <option value="France">France</option> <option value="French Guiana">French Guiana</option> <option value="French Polynesia">French Polynesia</option> <option value="Gabon">Gabon</option> <option value="Gambia">Gambia</option> <option value="Georgia">Georgia</option> <option value="Germany">Germany</option> <option value="Ghana">Ghana</option> <option value="Gibraltar">Gibraltar</option> <option value="Greece">Greece</option> <option value="Greenland">Greenland</option> <option value="Grenada">Grenada</option> <option value="Guadeloupe">Guadeloupe</option> <option value="Guam">Guam</option> <option value="Guatemala">Guatemala</option> <option value="Guinea">Guinea</option> <option value="Guinea-Bissau">Guinea-Bissau</option> <option value="Guyana">Guyana</option> <option value="Haiti">Haiti</option> <option value="Honduras">Honduras</option> <option value="Hong Kong">Hong Kong</option> <option value="Hungary">Hungary</option> <option value="Iceland">Iceland</option> <option value="India">India</option> <option value="Indonesia">Indonesia</option> <option value="Iran">Iran</option> <option value="Iraq">Iraq</option> <option value="Ireland">Ireland</option> <option value="Israel">Israel</option> <option value="Italy">Italy</option> <option value="Jamaica">Jamaica</option> <option value="Japan">Japan</option> <option value="Jordan">Jordan</option> <option value="Kazakhstan">Kazakhstan</option> <option value="Kenya">Kenya</option> <option value="Kiribati">Kiribati</option> <option value="Korea (north)">Korea (north)</option> <option value="Korea (south)">Korea (south)</option> <option value="Kuwait">Kuwait</option> <option value="Kyrgyzstan">Kyrgyzstan</option> <option value="Latvia">Latvia</option> <option value="Lebanon">Lebanon</option> <option value="Lesotho">Lesotho</option> <option value="Liberia">Liberia</option> <option value="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option> <option value="Liechtenstein">Liechtenstein</option> <option value="Lithuania">Lithuania</option> <option value="Luxembourg">Luxembourg</option> <option value="Macao">Macao</option> <option value="Macedonia">Macedonia</option> <option value="Madagascar">Madagascar</option> <option value="Malawi">Malawi</option> <option value="Malaysia">Malaysia</option> <option value="Maldives">Maldives</option> <option value="Mali">Mali</option> <option value="Malta">Malta</option> <option value="Marshall Islands">Marshall Islands</option> <option value="Martinique">Martinique</option> <option value="Mauritania">Mauritania</option> <option value="Mauritius">Mauritius</option> <option value="Mayotte">Mayotte</option> <option value="Mexico">Mexico</option> <option value="Micronesia">Micronesia</option> <option value="Moldova">Moldova</option> <option value="Monaco">Monaco</option> <option value="Mongolia">Mongolia</option> <option 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Territories</option> <option value="Panama">Panama</option> <option value="Papua New Guinea">Papua New Guinea</option> <option value="Paraguay">Paraguay</option> <option value="Peru">Peru</option> <option value="Philippines">Philippines</option> <option value="Pitcairn">Pitcairn</option> <option value="Poland">Poland</option> <option value="Portugal">Portugal</option> <option value="Puerto Rico">Puerto Rico</option> <option value="Qatar">Qatar</option> <option value="R脙漏union">Réunion</option> <option value="Romania">Romania</option> <option value="Russian Federation">Russian Federation</option> <option value="Rwanda">Rwanda</option> <option value="Saint Helena">Saint Helena</option> <option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option> <option value="Saint Lucia">Saint Lucia</option> <option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option> <option value="Saint Vincent">Saint Vincent</option> <option value="Samoa">Samoa</option> <option value="San Marino">San Marino</option> <option value="Sao Tome and Principe">Sao Tome and Principe</option> <option value="Saudi Arabia">Saudi Arabia</option> <option value="Senegal">Senegal</option> <option value="Serbia and Montenegro">Serbia and Montenegro</option> <option value="Seychelles">Seychelles</option> <option value="Sierra Leone">Sierra Leone</option> <option value="Singapore">Singapore</option> <option value="Slovakia">Slovakia</option> <option value="Slovenia">Slovenia</option> <option value="Solomon Islands">Solomon Islands</option> <option value="Somalia">Somalia</option> <option value="South Africa">South Africa</option> <option value="Spain">Spain</option> <option value="Sri Lanka">Sri Lanka</option> <option value="Sudan">Sudan</option> <option value="Suriname">Suriname</option> <option value="Swaziland">Swaziland</option> <option value="Sweden">Sweden</option> <option value="Switzerland">Switzerland</option> <option value="Syria">Syria</option> <option 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<option value="Venezuela">Venezuela</option> <option value="Vietnam">Vietnam</option> <option value="Virgin Islands (British)">Virgin Islands (British)</option> <option value="Wallis and Futuna Islands">Wallis and Futuna Islands</option> <option value="Western Sahara">Western Sahara</option> <option value="Yemen">Yemen</option> <option value="Zaire">Zaire</option> <option value="Zambia">Zambia</option> <option value="Zimbabwe">Zimbabwe</option> </select> <i></i> </label> </section> <section class="col col-6"> </section> </div> </fieldset> <header>Subscription Options</header> <h6>Choose your subscription.</h6> <fieldset> <section> <label class="checkbox"><input type="checkbox" value="yes" id="ezine" name="ezine" class="subscription-type"><i></i><strong><span style="color: #469744">Digital (Green) Access </span></strong> - Includes 6 digital issues per year for smartphones, tablets and computers</label> <label class="checkbox"><input type="checkbox" value="yes" id="printversion" name="printversion" class="subscription-type"><i></i><strong>Print Magazine</strong> - Includes 6 print issues per year</label> </section> </fieldset> <span id="user_registration" style="display: none;"> <input name="txtUsername" type="text" maxlength="50" id="txtUsername" /> <input name="txtPassword" type="password" maxlength="50" id="txtPassword" /> <input name="txtPassword2" type="password" maxlength="50" id="txtPassword2" /> </span> <h6>Subscription for:</h6> <fieldset> <section class="subscriber-matrix"> <label class="checkbox"><input type="checkbox" name="subscriber" value="patient " onclick="setVisible();"><i></i>Patient</label> <span id="patient" style="display: none;" class="indent-left-1x"> <strong class="heading">Please indicate all conditions that apply:</strong> <label class="checkbox"><input type="checkbox" name="patient_type" value="Primary immune deficiency" onclick="setVisible()"><i></i>Primary immune deficiency</label> <span id="patient_pid" style="display: none;" class="indent-left-1x"> <label class="checkbox"><input type="checkbox" name="patient_pid_type" value="Common variable immune deficiency"><i></i>Common variable immune deficiency</label> <label class="checkbox"><input type="checkbox" name="patient_pid_type" value="Selective IgA deficiency"><i></i>Selective IgA deficiency</label> <label class="checkbox"><input type="checkbox" name="patient_pid_type" value="Severe combined immune deficiency"><i></i>Severe combined immune deficiency</label> <label class="checkbox"><input type="checkbox" name="patient_pid_type" value="X-linked agammaglobulinemia"><i></i>X-linked agammaglobulinemia</label> <label class="checkbox"><input type="checkbox" name="patient_pid_type" class="patient-pid-type-other" value="PidOtherType"><i></i>Other</label> <label class="input"><input type="text" placeholder="Other PID type" name="patient_pid_other_type" value="" maxlength="255"></label> </span> <label class="checkbox"><input type="checkbox" name="patient_type" value="CIDP"><i></i>CIDP</label> <label class="checkbox"><input type="checkbox" name="patient_type" value="Guillain-Barre syndrome"><i></i>Guillain-Barré syndrome</label> <label class="checkbox"><input type="checkbox" name="patient_type" value="Chronic lymphocytic leukemia"><i></i>Chronic lymphocytic leukemia</label> <label class="checkbox"><input type="checkbox" name="patient_type" value="Kawasaki's disease"><i></i>Kawasaki's disease</label> <label class="checkbox"><input type="checkbox" name="patient_type" value="Myasthenia Gravis"><i></i>Myasthenia gravis</label> <label class="checkbox"><input type="checkbox" name="patient_type" value="Multiple Sclerosis"><i></i>Multiple sclerosis</label> <label class="checkbox"><input type="checkbox" name="patient_type" class="patient-type-other-neuropathy" value="Other Neuropathy"><i></i>Other neuropathy</label> <label class="input"><input type="text" placeholder="Other neuropathy type" name="patient_other_neuropathy_type" value="" maxlength="255"></label> <label class="checkbox"><input type="checkbox" name="patient_type" value="ITP"><i></i>ITP</label> <label class="checkbox"><input type="checkbox" name="patient_type" class="patient-type-other-myositis" value="Myositis"><i></i>Myositis</label> <label class="input"><input type="text" placeholder="Other myositis type" name="patient_myositis_type" value="" maxlength="255"></label> <label class="checkbox"><input type="checkbox" name="patient_type" class="patient-type-other" value="PatientOtherType"><i></i>Other</label> <label class="input"><input type="text" placeholder="Other patient type" name="patient_other_type" value="" maxlength="255"></label> <strong class="heading">Where do you receive IG therapy?</strong><br> <label class="checkbox"><input type="checkbox" name="patient_therapy_location" value="Doctors office"><i></i>Doctor's office</label> <label class="checkbox"><input type="checkbox" name="patient_therapy_location" value="Independent infusion center"><i></i>Independent infusion center</label> <label class="checkbox"><input type="checkbox" name="patient_therapy_location" value="Homecare"><i></i>Homecare</label> <label class="checkbox"><input type="checkbox" name="patient_therapy_location" value="Hospital"><i></i>Hospital outpatient</label> <label class="checkbox"><input type="checkbox" name="patient_therapy_location" value="Not yet started"><i></i>Not yet started</label> <label class="checkbox"><input type="checkbox" name="patient_therapy_location" class="patient-therapy-location-other" value="Other"><i></i>Other</label> <label class="input"><input type="text" placeholder="Other therapy location" name="patient_therapy_location_other" value="" maxlength="255"></label> </span> <label class="checkbox"><input type="checkbox" name="subscriber" value="family_friend" onclick="setVisible();"><i></i>Patient family member/friend</label> <span id="patient_family_member" style="display: none;" class="indent-left-1x"> <strong class="heading">Please indicate all conditions that apply:</strong> <label class="checkbox"><input type="checkbox" name="patient_family_friend_type" value="Primary immune deficiency" onclick="setVisible()"><i></i>Primary immune deficiency</label> <span id="family_friend_pid" style="display:none;" class="indent-left-1x"> <label class="checkbox"><input type="checkbox" name="family_friend_pid_type" value="Common variable immune deficiency"><i></i>Common variable immune deficiency</label> <label class="checkbox"><input type="checkbox" name="family_friend_pid_type" value="Selective IgA deficiency"><i></i>Selective IgA deficiency</label> <label class="checkbox"><input type="checkbox" name="family_friend_pid_type" value="Severe combined immune deficiency"><i></i>Severe combined immune deficiency</label> <label class="checkbox"><input type="checkbox" name="family_friend_pid_type" value="X-linked agammaglobulinemia"><i></i>X-linked agammaglobulinemia</label> <label class="checkbox"><input type="checkbox" name="family_friend_pid_type" class="family-friend-pid-type-other" value="FamilyPidOtherType"><i></i>Other</label> <label class="input"><input type="text" placeholder="Other PID type" name="family_friend_pid_other_type" value="" maxlength="255"></label> </span> <label class="checkbox"><input type="checkbox" name="patient_family_friend_type" value="CIDP"><i></i>CIDP</label> <label class="checkbox"><input type="checkbox" name="patient_family_friend_type" value="Guillain-Barre syndrome"><i></i>Guillain-Barr脙漏 syndrome</label> <label class="checkbox"><input type="checkbox" name="patient_family_friend_type" value="Chronic lymphocytic leukemia"><i></i>Chronic lymphocytic leukemia</label> <label class="checkbox"><input type="checkbox" name="patient_family_friend_type" value="Kawasaki's disease"><i></i>Kawasaki's disease</label> <label class="checkbox"><input type="checkbox" name="patient_family_friend_type" value="Myasthenia Gravis"><i></i>Myasthenia gravis</label> <label class="checkbox"><input type="checkbox" name="patient_family_friend_type" value="Multiple Sclerosis"><i></i>Multiple sclerosis</label> <label class="checkbox"><input type="checkbox" name="patient_family_friend_type" class="patient-family-friend-type-other-neuropathy" value="Other Neuropathy"><i></i>Other neuropathy</label> <label class="input"><input type="text" placeholder="Other neuropathy type" name="patient_family_friend_other_neuropathy_type" value="" maxlength="255"></label> <label class="checkbox"><input type="checkbox" name="patient_family_friend_type" value="ITP"><i></i>ITP</label> <label class="checkbox"><input type="checkbox" name="patient_family_friend_type" class="patient-family-friend-type-other-myositis" value="Myositis"><i></i>Myositis</label> <label class="input"><input type="text" placeholder="Other myositis type" name="patient_family_friend_myositis_type" value="" maxlength="255"></label> <label class="checkbox"><input type="checkbox" name="patient_family_friend_type" class="patient-family-friend-type-other" value="Other"><i></i>Other</label> <label class="input"><input type="text" placeholder="Other type friend / family member" name="patient_family_friend_other_type" value="" maxlength="255"></label> <strong class="heading">Where does your family member/friend receive IG therapy?</strong> <label class="checkbox"><input type="checkbox" name="patient_family_friend_therapy_location" value="Doctor's office"><i></i>Doctor's office</label> <label class="checkbox"><input type="checkbox" name="patient_family_friend_therapy_location" value="Independent infusion center">Independent infusion center</label> <label class="checkbox"><input type="checkbox" name="patient_family_friend_therapy_location" value="Homecare"><i></i>Homecare</label> <label class="checkbox"><input type="checkbox" name="patient_family_friend_therapy_location" value="Hospital"><i></i>Hospital outpatient</label> <label class="checkbox"><input type="checkbox" name="patient_family_friend_therapy_location" value="Not yet started"><i></i>Not yet started</label> <label class="checkbox"><input type="checkbox" name="patient_family_friend_therapy_location" class="patient-family-friend-type-therapy-location-other" value="Other"><i></i>Other</label> <label class="input"><input type="text" placeholder="Other therapy location" name="patient_family_friend_therapy_location_other" value="" maxlength="255"></label> </span> <label class="checkbox"><input type="checkbox" name="subscriber" value="pat_organization" class="subscriber-patient-organization" onclick="setVisible();"><i></i>Patient organization</label> <span id="pat_organization" style="display: none;" class="indent-left-1x"> <label class="input"><input type="text" placeholder="Organization name" name="patient_organization_name" value="" maxlength="255"></label> Qty of Magazines: <label class="input"><input name="txtPatOrgQuantity" type="text" maxlength="3" id="txtPatOrgQuantity" name="txtPatOrgQuantity" /></label> </span> <label class="checkbox"><input type="checkbox" name="subscriber" value="healthcare_professional" onclick="setVisible();"><i></i>Healthcare professional</label> <span id="healthcare_professional" style="display: none;" class="indent-left-1x"> <strong class="heading">Please indicate all specialities that apply:</strong> <label class="checkbox"><input type="checkbox" name="healthcare_professional_type" value="Allergy/Immunology"><i></i>Allergy/Immunology</label> <label class="checkbox"><input type="checkbox" name="healthcare_professional_type" value="Dermatology"><i></i>Dermatology</label> <label class="checkbox"><input type="checkbox" name="healthcare_professional_type" value="General Practice/Internal Medicine"><i></i>General practice/internal medicine</label> <label class="checkbox"><input type="checkbox" name="healthcare_professional_type" value="Hematology/Oncology"><i></i>Hematology/Oncology</label> <label class="checkbox"><input type="checkbox" name="healthcare_professional_type" value="Infectious Disease"><i></i>Infectious disease</label> <label class="checkbox"><input type="checkbox" name="healthcare_professional_type" value="Infusion Nurse"><i></i>Infusion nurse</label> <label class="checkbox"><input type="checkbox" name="healthcare_professional_type" value="Neurology"><i></i>Neurology</label> <label class="checkbox"><input type="checkbox" name="healthcare_professional_type" value="Pediatrics"><i></i>Pediatrics</label> <label class="checkbox"><input type="checkbox" name="healthcare_professional_type" value="Pharmacist"><i></i>Pharmacist</label> <label class="checkbox"><input type="checkbox" name="healthcare_professional_type" value="Pulmonology"><i></i>Pulmonology</label> <label class="checkbox"><input type="checkbox" name="healthcare_professional_type" value="Rheumatology"><i></i>Rheumatology</label> <label class="checkbox"><input type="checkbox" name="healthcare_professional_type" value="Specialty 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