{"id":"491","field_id":9,"fields":{"6":{"id":"6","type":"html","name":"","code":"<div class=\"cf-field \" data-cf-field-id=\"185287\" data-cf-field-type=\"paragraph\" data-cf-grow=\"false\"><div style=\"font-size: 14px;\"><p><strong>PERSONAL DECLARATION<\/strong><\/p>\r\n<p>I am receiving from Valentine Wigs, 44 Croft Meadow, Bamber Bridge, Preston PR5 8HX wigs supplied to me for domestic or my personal use to suit my condition and I claim relief from Value Added Tax for these goods and any further goods whilst my condition remains. VAT relief cannot be claimed for accessories or after care products.<\/p>\r\n<p>Please be aware that there are penalties for making false declarations. If you are in any doubt as to whether you are eligible to receive goods or services zero-rated for VAT you should consult Notice 701\/7 VAT Reliefs For Disabled People or contact the National Advice Service on 0300 123 1073.<\/p>\r\n<p>I declare that I am chronically sick or have a disabling condition as described below.<\/p><\/div><\/div>\r\n\r\n\r\nName of My Doctor and\/or Medical Consultant <span class=\"wpforms-required-label\">*<\/span>\r\n<input type = \"text\" name = \"doctor_name\" required\/>\r\n         <br>\r\n\r\n\r\n","label_disable":"1","css":""},"7":{"id":"7","type":"textarea","label":"Address of Doctor\/Medical Consultant","description":"","required":"1","size":"medium","placeholder":"","limit_count":"1","limit_mode":"characters","default_value":"","css":""},"8":{"id":"8","type":"html","name":"","code":"\r\nDate of My Claim (Today's Date) <span class=\"wpforms-required-label\">*<\/span><input type = \"text\" name = \"DOB\" required\/>\r\n<p>Print your full name here verifying you have completed this form honestly to the best of your knowledge. I am a necessity wearer of wigs due to the medical condition stated<\/p>\r\n\r\nSigned (Print your full name) <span class=\"wpforms-required-label\">*<\/span><input type = \"text\" name = \"signed-img\" required\/>\r\n\r\n","label_disable":"1","css":""},"1":{"id":"1","type":"name","label":"Name","format":"first-last","description":"","required":"1","size":"medium","simple_placeholder":"","simple_default":"","first_placeholder":"","first_default":"","middle_placeholder":"","middle_default":"","last_placeholder":"","last_default":"","css":""},"2":{"id":"2","type":"text","label":"Username","description":"","required":"1","size":"medium","placeholder":"","limit_count":"1","limit_mode":"characters","default_value":"","css":"","input_mask":""},"3":{"id":"3","type":"email","label":"Email","description":"","required":"1","size":"medium","placeholder":"","confirmation_placeholder":"","default_value":"","css":"","meta":{"nickname":"email","delete":false}},"4":{"id":"4","type":"password","label":"Password","description":"","required":"1","size":"medium","placeholder":"","confirmation_placeholder":"","default_value":"","css":""},"5":{"id":"5","type":"textarea","label":"Short Bio","description":"Share a little information about yourself.","size":"small","placeholder":"","limit_count":"1","limit_mode":"characters","default_value":"","css":""}},"settings":{"form_title":"demo","form_desc":"","form_class":"","submit_text":"Submit","submit_text_processing":"","submit_class":"","honeypot":"1","notification_enable":"1","notifications":{"1":{"notification_name":"Default Notification","email":"{admin_email}","subject":"New Entry: demo","sender_name":"Liberty","sender_address":"{admin_email}","replyto":"","message":"{all_fields}"}},"confirmations":{"1":{"name":"Default Confirmation","type":"message","message":"<p>Thanks for contacting us! We will be in touch with you shortly.<\/p>","message_scroll":"1","page":"212","redirect":""}},"registration_username":"2","registration_name":"1","registration_password":"4","registration_website":"","registration_bio":"5","registration_role":"subscriber","registration_email_user":"1","registration_email_admin":"1","registration_activation_method":"user","registration_activation_confirmation":""},"meta":{"template":"user_registration"}}