{"id":164,"date":"2025-09-19T23:10:05","date_gmt":"2025-09-19T23:10:05","guid":{"rendered":"https:\/\/orthodontist.clear-smile.co.il\/%d7%98%d7%95%d7%a4%d7%a1-%d7%aa%d7%99%d7%a7\/"},"modified":"2026-02-14T21:43:47","modified_gmt":"2026-02-14T21:43:47","slug":"%d7%98%d7%95%d7%a4%d7%a1-%d7%aa%d7%99%d7%a7","status":"publish","type":"page","link":"https:\/\/orthodontist.clear-smile.co.il\/he\/%d7%98%d7%95%d7%a4%d7%a1-%d7%aa%d7%99%d7%a7\/","title":{"rendered":"\u05d8\u05d5\u05e4\u05e1 \u05ea\u05d9\u05e7"},"content":{"rendered":"\n<div class=\"wp-block-columns alignfull is-layout-flex wp-container-core-columns-is-layout-28f84493 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">        <div class=\"container-fluid cs-new-case-container\">\n            \n            <div class=\"row\" id=\"case-form-row\">\n\n                <aside class=\"col-md-3\">\n                    <nav class=\"cs-steps-nav\">\n                        <div class=\"cs-stepper\">\n                            <div class=\"cs-step cs-step-link active\" data-step=\"1\">\n                                <div class=\"step-icon\">1<\/div>\n                                <div class=\"step-label\">\u05de\u05d9\u05d3\u05e2 \u05d1\u05e1\u05d9\u05e1\u05d9<\/div>\n                            <\/div>\n                            <div class=\"cs-step cs-step-link \" data-step=\"2\">\n                                <div class=\"step-icon\">2<\/div>\n                                <div class=\"step-label\">\u05de\u05d5\u05d3\u05dc \u05e0\u05ea\u05d5\u05e0\u05d9\u05dd<\/div>\n                            <\/div>\n                            <div class=\"cs-step cs-step-link \" data-step=\"3\">\n                                <div class=\"step-icon\">3<\/div>\n                                <div class=\"step-label\">\u05d0\u05d1\u05d7\u05e0\u05d4 \u05e7\u05dc\u05d9\u05e0\u05d9\u05ea<\/div>\n                            <\/div>\n                            <div class=\"cs-step cs-step-link \" data-step=\"4\">\n                                <div class=\"step-icon\">4<\/div>\n                                <div class=\"step-label\">\u05d4\u05d2\u05d3\u05e8\u05ea \u05de\u05db\u05e9\u05d9\u05e8<\/div>\n                            <\/div>\n                            <div class=\"cs-step cs-step-link \" data-step=\"5\">\n                                <div class=\"step-icon\">5<\/div>\n                                <div class=\"step-label\">\u05ea\u05db\u05e0\u05d5\u05df \u05de\u05d9\u05e7\u05d5\u05dd \u05d9\u05e2\u05d3<\/div>\n                            <\/div>\n                            <div class=\"cs-step cs-step-link \" data-step=\"6\">\n                                <div class=\"step-icon\">6<\/div>\n                                <div class=\"step-label\">\u05ea\u05d5\u05db\u05e0\u05d9\u05ea \u05d9\u05d9\u05e9\u05d5\u05e8<\/div>\n                            <\/div>\n                            <div class=\"cs-step cs-step-link \" data-step=\"7\">\n                                <div class=\"step-icon\">7<\/div>\n                                <div class=\"step-label\">\u05ea\u05e6\u05d5\u05d2\u05d4 \u05de\u05e7\u05d3\u05d9\u05de\u05d4 \u05d5\u05d4\u05d2\u05e9\u05d4<\/div>\n                            <\/div>\n                        <\/div>\n                    <\/nav>\n                <\/aside>\n\n                <section class=\"cs-steps-content col-md-9\">\n\n                    <div class=\"cs-step-pane\" data-step=\"1\">\n                            <div class=\"mb-3\">\n        <strong>\u05de\u05e1\u05e4\u05e8 \u05de\u05e7\u05e8\u05d4:<\/strong> <span class=\"text-primary case-number\">\u05d8\u05d5\u05e2\u05df...<\/span>\n    <\/div>\n\t<div class=\"mb-3\">\n\t\t<label for=\"cs_patient_name\" class=\"form-label\">\u05e9\u05dd \u05d4\u05de\u05d8\u05d5\u05e4\u05dc <span class=\"text-danger\">*<\/span><\/label>\n\t\t<input type=\"text\" id=\"cs_patient_name\" name=\"patient_name\" class=\"form-control\" placeholder=\"\u05e9\u05dd \u05d0\u05de\u05d9\u05ea\u05d9\" required>\n\t<\/div>\n\t<div class=\"mb-3\">\n\t\t<label class=\"form-label\">\u05de\u05d2\u05d3\u05e8 <span class=\"text-danger\">*<\/span><\/label>\n\t\t<div class=\"btn-group\" role=\"group\" aria-label=\"\u05d1\u05d7\u05d9\u05e8\u05ea \u05de\u05d2\u05d3\u05e8\">\n\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"gender\" id=\"cs_gender_male\" value=\"male\" autocomplete=\"off\" checked required>\n\t\t\t<label class=\"btn btn-choice\" for=\"cs_gender_male\">\u05d6\u05db\u05e8<\/label>\n\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"gender\" id=\"cs_gender_female\" value=\"female\" autocomplete=\"off\">\n\t\t\t<label class=\"btn btn-choice\" for=\"cs_gender_female\">\u05e0\u05e7\u05d1\u05d4<\/label>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"mb-3\">\n\t\t<label for=\"cs_mechanism\" class=\"form-label\">\u05de\u05e0\u05d2\u05e0\u05d5\u05df <span class=\"text-danger\">*<\/span><\/label>\n\t\t<select id=\"cs_mechanism\" name=\"mechanism\" class=\"form-select\" required>\n\t\t\t<option value=\"Claudio\" selected>\u05e7\u05dc\u05d0\u05d5\u05d3\u05d9\u05d5<\/option>\n\t\t<\/select>\n\t<\/div>\n\t<div class=\"mb-3\">\n\t\t<label for=\"cs_dob\" class=\"form-label\">\u05ea\u05d0\u05e8\u05d9\u05da \u05dc\u05d9\u05d3\u05d4 <span class=\"text-danger\">*<\/span><\/label>\n\t\t<input type=\"text\" id=\"cs_dob\" name=\"dob\" class=\"form-control\" placeholder=\"\u05d0\u05e0\u05d0 \u05d1\u05d7\u05e8 \u05ea\u05d0\u05e8\u05d9\u05da \u05dc\u05d9\u05d3\u05d4\" required readonly>\n\t<\/div>\n\t<div class=\"mb-3 d-flex align-items-center\">\n\t\t<label class=\"form-label me-3 mb-0\">\u05d2\u05d9\u05dc<\/label>\n\t\t<div class=\"input-group input-group-sm cs-input-spinner\" style=\"width: 120px;\">\n   \t\t <button class=\"btn\" type=\"button\" id=\"cs_age_decrement\">\u2212<\/button>\n  \t\t  <input type=\"number\" id=\"cs_age\" name=\"age\" class=\"form-control text-center\" value=\"0\" min=\"0\" readonly>\n  \t\t  <button class=\"btn\" type=\"button\" id=\"cs_age_increment\">+<\/button>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"mb-3\">\n\t\t<label for=\"cs_outpatient_case_number\" class=\"form-label\">\u05de\u05e1\u05e4\u05e8 \u05de\u05e7\u05e8\u05d4 \u05d0\u05de\u05d1\u05d5\u05dc\u05d8\u05d5\u05e8\u05d9<\/label>\n\t\t<input type=\"text\" id=\"cs_outpatient_case_number\" name=\"outpatient_case_number\" class=\"form-control\" placeholder=\"\u05d0\u05e0\u05d0 \u05d4\u05d6\u05df \u05de\u05e1\u05e4\u05e8 \u05de\u05e7\u05e8\u05d4 \u05d0\u05de\u05d1\u05d5\u05dc\u05d8\u05d5\u05e8\u05d9\">\n\t<\/div>\n\t                        <div class=\"d-flex justify-content-end mt-5\">\n                            <button type=\"button\" class=\"btn btn-primary cs-next-step btn-lg\">\u05e9\u05dc\u05d1 \u05d4\u05d1\u05d0<\/button>\n                        <\/div>\n                    <\/div>\n\n                    <div class=\"cs-step-pane d-none\" data-step=\"2\">\n                        \t<h4>\u05de\u05d5\u05d3\u05dc \u05e0\u05ea\u05d5\u05e0\u05d9\u05dd<\/h4>\n\n\t<div class=\"row\">\n\t\t<div class=\"col-md-12\">\n\t\t\t<div class=\"mb-4 p-3 border rounded shadow-sm\">\n\t\t\t\t<h5 class=\"mb-3\">\u05ea\u05dc\u05d5\u05e0\u05d5\u05ea<\/h5>\n\n\t\t\t\t<div class=\"mb-3\">\n\t\t\t\t\t<div class=\"form-label fw-semibold\">\u05d1\u05e2\u05d9\u05d5\u05ea \u05d3\u05e0\u05d8\u05dc\u05d9\u05d5\u05ea<\/div>\n\t\t\t\t\t<div class=\"d-flex flex-wrap gap-2\" role=\"group\" aria-label=\"\u05d1\u05e2\u05d9\u05d5\u05ea \u05d3\u05e0\u05d8\u05dc\u05d9\u05d5\u05ea\">\n\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"dental_problems[]\" id=\"dp_teeth_not_crooked\" value=\"teeth_are_not_crooked\" autocomplete=\"off\">\n\t\t\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"dp_teeth_not_crooked\">\u05d4\u05e9\u05d9\u05e0\u05d9\u05d9\u05dd \u05d0\u05d9\u05e0\u05df \u05e2\u05e7\u05d5\u05de\u05d5\u05ea<\/label>\n\n\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"dental_problems[]\" id=\"dp_tooth_protrusion\" value=\"tooth_protrusion\" autocomplete=\"off\">\n\t\t\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"dp_tooth_protrusion\">\u05d1\u05dc\u05d9\u05d8\u05ea \u05e9\u05df<\/label>\n\n\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"dental_problems[]\" id=\"dp_gap_between\" value=\"gap_between_the_dentition\" autocomplete=\"off\">\n\t\t\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"dp_gap_between\">\u05e8\u05d5\u05d5\u05d7 \u05d1\u05d9\u05df \u05d4\u05e9\u05d9\u05e0\u05d9\u05d9\u05dd<\/label>\n\n\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"dental_problems[]\" id=\"dp_mouth_protrusion\" value=\"mouth_protrusion\" autocomplete=\"off\">\n\t\t\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"dp_mouth_protrusion\">\u05d1\u05dc\u05d9\u05d8\u05ea \u05e4\u05d4<\/label>\n\n\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"dental_problems[]\" id=\"dp_poor_bite\" value=\"poor_bite\" autocomplete=\"off\">\n\t\t\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"dp_poor_bite\">\u05e0\u05e9\u05d9\u05db\u05d4 \u05dc\u05e7\u05d5\u05d9\u05d4<\/label>\n\n\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"dental_problems[]\" id=\"dp_closing\" value=\"closing\" autocomplete=\"off\">\n\t\t\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"dp_closing\">\u05e1\u05d2\u05d9\u05e8\u05d4<\/label>\n\n\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"dental_problems[]\" id=\"dp_anti_combination\" value=\"anti_combination\" autocomplete=\"off\">\n\t\t\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"dp_anti_combination\">\u05d0\u05e0\u05d8\u05d9-\u05e9\u05d9\u05dc\u05d5\u05d1<\/label>\n\n\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"dental_problems[]\" id=\"dp_other_dental\" value=\"other\" autocomplete=\"off\">\n\t\t\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"dp_other_dental\">\u05d0\u05d7\u05e8<\/label>\n\t\t\t\t\t\t<div class=\"mt-2 w-100\" id=\"dp_other_text_wrapper\" style=\"display:none;\">\n\t\t\t\t\t\t\t<input type=\"text\" id=\"dp_other_text\" name=\"dental_problems_other\" class=\"form-control\" placeholder=\"\u05d0\u05e0\u05d0 \u05e6\u05d9\u05d9\u05df \u05d0\u05d7\u05e8\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\n\t\t\t\t<div class=\"mb-3\">\n\t\t\t\t\t<div class=\"form-label fw-semibold\">\u05d1\u05e2\u05d9\u05d5\u05ea \u05dc\u05e1\u05ea<\/div>\n\t\t\t\t\t<div class=\"form-label fw-semibold\" role=\"group\" aria-label=\"\u05d1\u05e2\u05d9\u05d5\u05ea \u05dc\u05e1\u05ea\">\n\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"jaw_problems[]\" id=\"jp_maxillary_protrusion\" value=\"maxillary_protrusion\" autocomplete=\"off\">\n\t\t\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"jp_maxillary_protrusion\">\u05d1\u05dc\u05d9\u05d8\u05ea \u05dc\u05e1\u05ea \u05e2\u05dc\u05d9\u05d5\u05e0\u05d4<\/label>\n\n\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"jaw_problems[]\" id=\"jp_lower_jaw_retracted\" value=\"the_lower_jaw_is_retracted\" autocomplete=\"off\">\n\t\t\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"jp_lower_jaw_retracted\">\u05d4\u05dc\u05e1\u05ea \u05d4\u05ea\u05d7\u05ea\u05d5\u05e0\u05d4 \u05e0\u05e1\u05d5\u05d2\u05d4<\/label>\n\n\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"jaw_problems[]\" id=\"jp_bimaxillary_protrusion\" value=\"bimaxillary_protrusion\" autocomplete=\"off\">\n\t\t\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"jp_bimaxillary_protrusion\">\u05d1\u05dc\u05d9\u05d8\u05d4 \u05d3\u05d5-\u05dc\u05e1\u05ea\u05d9\u05ea<\/label>\n\n\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"jaw_problems[]\" id=\"jp_other_jaw\" value=\"other\" autocomplete=\"off\">\n\t\t\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"jp_other_jaw\">\u05d0\u05d7\u05e8<\/label>\n\n\t\t\t\t\t\t<div class=\"mt-2 w-100\" id=\"jp_other_text_wrapper\" style=\"display:none;\">\n\t\t\t\t\t\t\t<input type=\"text\" id=\"jp_other_text\" name=\"jaw_problems_other\" class=\"form-control\" placeholder=\"\u05d0\u05e0\u05d0 \u05e6\u05d9\u05d9\u05df \u05d0\u05d7\u05e8\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t<!-- FacePhoto row start here -->\n\t\t\t<div class=\"mb-4\">\n\t\t\t\t<div class=\"fw-semibold mb-2\">\u05ea\u05de\u05d5\u05e0\u05ea \u05e4\u05e0\u05d9\u05dd<\/div>\n\t\t\t\t<div class=\"row g-3\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-md-6\">\n\t\t\t\t\t\t\t<div class=\"position-relative border rounded image-upload-wrapper\">\n\t\t\t\t\t\t\t\t<label for=\"upload_front\" class=\"w-100 h-100 m-0 d-flex flex-column align-items-center justify-content-center text-center\">\n\t\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/orthodontist.clear-smile.co.il\/wp-content\/plugins\/clear-smile-orthodontist-case-system\/\/assets\/images\/face\/front.png\" alt=\"\u05ea\u05de\u05d5\u05e0\u05d4 \u05d7\u05d6\u05d9\u05ea\u05d9\u05ea\" class=\"img-fluid\" id=\"front_preview\">\n\t\t\t\t\t\t\t\t\t<div class=\"mt-1 small\">\u05dc\u05d7\u05e5 \u05dc\u05d4\u05e2\u05dc\u05d0\u05d4\/\u05d2\u05e8\u05d5\u05e8 \u05d0\u05ea \u05d4\u05ea\u05de\u05d5\u05e0\u05d4<\/div>\n\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" accept=\"image\/*\" id=\"upload_front\" name=\"face_photos[front]\" class=\"d-none cs-face-photo-input\" data-target-preview=\"front\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"mt-1 small text-center\">\u05ea\u05de\u05d5\u05e0\u05d4 \u05d7\u05d6\u05d9\u05ea\u05d9\u05ea<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-md-6\">\n\t\t\t\t\t\t\t<div class=\"position-relative border rounded image-upload-wrapper\">\n\t\t\t\t\t\t\t\t<label for=\"upload_side\" class=\"w-100 h-100 m-0 d-flex flex-column align-items-center justify-content-center text-center\">\n\t\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/orthodontist.clear-smile.co.il\/wp-content\/plugins\/clear-smile-orthodontist-case-system\/\/assets\/images\/face\/side.png\" alt=\"\u05d7\u05d9\u05d5\u05da \u05d7\u05d9\u05d5\u05d1\u05d9\" class=\"img-fluid\" id=\"side_preview\">\n\t\t\t\t\t\t\t\t\t<div class=\"mt-1 small\">\u05dc\u05d7\u05e5 \u05dc\u05d4\u05e2\u05dc\u05d0\u05d4\/\u05d2\u05e8\u05d5\u05e8 \u05d0\u05ea \u05d4\u05ea\u05de\u05d5\u05e0\u05d4<\/div>\n\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" accept=\"image\/*\" id=\"upload_side\" name=\"face_photos[side]\" class=\"d-none cs-face-photo-input\" data-target-preview=\"side\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"mt-1 small text-center\">\u05d7\u05d9\u05d5\u05da \u05d7\u05d9\u05d5\u05d1\u05d9<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-md-6\">\n\t\t\t\t\t\t\t<div class=\"position-relative border rounded image-upload-wrapper\">\n\t\t\t\t\t\t\t\t<label for=\"upload_side45\" class=\"w-100 h-100 m-0 d-flex flex-column align-items-center justify-content-center text-center\">\n\t\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/orthodontist.clear-smile.co.il\/wp-content\/plugins\/clear-smile-orthodontist-case-system\/\/assets\/images\/face\/side45.png\" alt=\"\u05ea\u05de\u05d5\u05e0\u05ea \u05e6\u05d3 45\u00b0\" class=\"img-fluid\" id=\"side45_preview\">\n\t\t\t\t\t\t\t\t\t<div class=\"mt-1 small\">\u05dc\u05d7\u05e5 \u05dc\u05d4\u05e2\u05dc\u05d0\u05d4\/\u05d2\u05e8\u05d5\u05e8 \u05d0\u05ea \u05d4\u05ea\u05de\u05d5\u05e0\u05d4<\/div>\n\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" accept=\"image\/*\" id=\"upload_side45\" name=\"face_photos[side45]\" class=\"d-none cs-face-photo-input\" data-target-preview=\"side45\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"mt-1 small text-center\">\u05ea\u05de\u05d5\u05e0\u05ea \u05e6\u05d3 45\u00b0<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-md-6\">\n\t\t\t\t\t\t\t<div class=\"position-relative border rounded image-upload-wrapper\">\n\t\t\t\t\t\t\t\t<label for=\"upload_smile\" class=\"w-100 h-100 m-0 d-flex flex-column align-items-center justify-content-center text-center\">\n\t\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/orthodontist.clear-smile.co.il\/wp-content\/plugins\/clear-smile-orthodontist-case-system\/\/assets\/images\/face\/smile.png\" alt=\"\u05ea\u05de\u05d5\u05e0\u05ea \u05d7\u05d9\u05d5\u05da\" class=\"img-fluid\" id=\"smile_preview\">\n\t\t\t\t\t\t\t\t\t<div class=\"mt-1 small\">\u05dc\u05d7\u05e5 \u05dc\u05d4\u05e2\u05dc\u05d0\u05d4\/\u05d2\u05e8\u05d5\u05e8 \u05d0\u05ea \u05d4\u05ea\u05de\u05d5\u05e0\u05d4<\/div>\n\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" accept=\"image\/*\" id=\"upload_smile\" name=\"face_photos[smile]\" class=\"d-none cs-face-photo-input\" data-target-preview=\"smile\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"mt-1 small text-center\">\u05ea\u05de\u05d5\u05e0\u05ea \u05d7\u05d9\u05d5\u05da<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<!-- FacePhoto row end here -->\n\n\t\t\t<!-- OralPhoto row start here -->\n\t\t\t<div class=\"mb-4\">\n\t\t\t\t<div class=\"fw-semibold mb-2\">\u05ea\u05de\u05d5\u05e0\u05d4 \u05d3\u05e0\u05d8\u05dc\u05d9\u05ea<\/div>\n\t\t\t\t<div class=\"row g-3\">\n\t\t\t\t\t<!-- First row: Maxillary and Mandible -->\n\t\t\t\t\t<div class=\"col-md-6\">\n\t\t\t\t\t\t<div class=\"position-relative border rounded image-upload-wrapper\" >\n\t\t\t\t\t\t\t<label for=\"upload_maxillary\" class=\"w-100 h-100 m-0 d-flex flex-column align-items-center justify-content-center text-center\">\n\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/orthodontist.clear-smile.co.il\/wp-content\/plugins\/clear-smile-orthodontist-case-system\/\/assets\/images\/oral\/maxillary.png\" alt=\"\u05dc\u05e1\u05ea \u05e2\u05dc\u05d9\u05d5\u05e0\u05d4\" class=\"img-fluid\" id=\"maxillary_preview\">\n\t\t\t\t\t\t\t\t<div class=\"mt-1 small\">\u05dc\u05d7\u05e5 \u05dc\u05d4\u05e2\u05dc\u05d0\u05d4\/\u05d2\u05e8\u05d5\u05e8 \u05d0\u05ea \u05d4\u05ea\u05de\u05d5\u05e0\u05d4<\/div>\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<input type=\"file\" accept=\"image\/*\" id=\"upload_maxillary\" name=\"oral_photos[maxillary]\" class=\"d-none cs-face-photo-input\" data-target-preview=\"maxillary\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mt-1 small text-center\">\u05dc\u05e1\u05ea \u05e2\u05dc\u05d9\u05d5\u05e0\u05d4<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"col-md-6\">\n\t\t\t\t\t\t<div class=\"position-relative border rounded image-upload-wrapper\" >\n\t\t\t\t\t\t\t<label for=\"upload_mandible\" class=\"w-100 h-100 m-0 d-flex flex-column align-items-center justify-content-center text-center\">\n\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/orthodontist.clear-smile.co.il\/wp-content\/plugins\/clear-smile-orthodontist-case-system\/\/assets\/images\/oral\/mandible.png\" alt=\"\u05dc\u05e1\u05ea \u05ea\u05d7\u05ea\u05d5\u05e0\u05d4\" class=\"img-fluid\" id=\"mandible_preview\">\n\t\t\t\t\t\t\t\t<div class=\"mt-1 small\">\u05dc\u05d7\u05e5 \u05dc\u05d4\u05e2\u05dc\u05d0\u05d4\/\u05d2\u05e8\u05d5\u05e8 \u05d0\u05ea \u05d4\u05ea\u05de\u05d5\u05e0\u05d4<\/div>\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<input type=\"file\" accept=\"image\/*\" id=\"upload_mandible\" name=\"oral_photos[mandible]\" class=\"d-none cs-face-photo-input\" data-target-preview=\"mandible\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mt-1 small text-center\">\u05dc\u05e1\u05ea \u05ea\u05d7\u05ea\u05d5\u05e0\u05d4<\/div>\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<!-- Second row: Right Bite, Frontal Bite, Left Bite -->\n\t\t\t\t\t<div class=\"col-md-4\">\n\t\t\t\t\t\t<div class=\"position-relative border rounded image-upload-wrapper\" >\n\t\t\t\t\t\t\t<label for=\"upload_right_bite\" class=\"w-100 h-100 m-0 d-flex flex-column align-items-center justify-content-center text-center\">\n\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/orthodontist.clear-smile.co.il\/wp-content\/plugins\/clear-smile-orthodontist-case-system\/\/assets\/images\/oral\/right_bite.png\" alt=\"\u05e0\u05e9\u05d9\u05db\u05d4 \u05d9\u05de\u05e0\u05d9\u05ea\" class=\"img-fluid\" id=\"right_bite_preview\">\n\t\t\t\t\t\t\t\t<div class=\"mt-1 small\">\u05dc\u05d7\u05e5 \u05dc\u05d4\u05e2\u05dc\u05d0\u05d4\/\u05d2\u05e8\u05d5\u05e8 \u05d0\u05ea \u05d4\u05ea\u05de\u05d5\u05e0\u05d4<\/div>\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<input type=\"file\" accept=\"image\/*\" id=\"upload_right_bite\" name=\"oral_photos[right_bite]\" class=\"d-none cs-face-photo-input\" data-target-preview=\"right_bite\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mt-1 small text-center\">\u05e0\u05e9\u05d9\u05db\u05d4 \u05d9\u05de\u05e0\u05d9\u05ea<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"col-md-4\">\n\t\t\t\t\t\t<div class=\"position-relative border rounded image-upload-wrapper\" >\n\t\t\t\t\t\t\t<label for=\"upload_frontal_bite\" class=\"w-100 h-100 m-0 d-flex flex-column align-items-center justify-content-center text-center\">\n\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/orthodontist.clear-smile.co.il\/wp-content\/plugins\/clear-smile-orthodontist-case-system\/\/assets\/images\/oral\/frontal_bite.png\" alt=\"\u05e0\u05e9\u05d9\u05db\u05d4 \u05d7\u05d6\u05d9\u05ea\u05d9\u05ea\" class=\"img-fluid\" id=\"frontal_bite_preview\">\n\t\t\t\t\t\t\t\t<div class=\"mt-1 small\">\u05dc\u05d7\u05e5 \u05dc\u05d4\u05e2\u05dc\u05d0\u05d4\/\u05d2\u05e8\u05d5\u05e8 \u05d0\u05ea \u05d4\u05ea\u05de\u05d5\u05e0\u05d4<\/div>\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<input type=\"file\" accept=\"image\/*\" id=\"upload_frontal_bite\" name=\"oral_photos[frontal_bite]\" class=\"d-none cs-face-photo-input\" data-target-preview=\"frontal_bite\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mt-1 small text-center\">\u05e0\u05e9\u05d9\u05db\u05d4 \u05d7\u05d6\u05d9\u05ea\u05d9\u05ea<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"col-md-4\">\n\t\t\t\t\t\t<div class=\"position-relative border rounded image-upload-wrapper\" >\n\t\t\t\t\t\t\t<label for=\"upload_left_bite\" class=\"w-100 h-100 m-0 d-flex flex-column align-items-center justify-content-center text-center\">\n\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/orthodontist.clear-smile.co.il\/wp-content\/plugins\/clear-smile-orthodontist-case-system\/\/assets\/images\/oral\/left_bite.png\" alt=\"\u05e0\u05e9\u05d9\u05db\u05d4 \u05e9\u05de\u05d0\u05dc\u05d9\u05ea\" class=\"img-fluid\" id=\"left_bite_preview\">\n\t\t\t\t\t\t\t\t<div class=\"mt-1 small\">\u05dc\u05d7\u05e5 \u05dc\u05d4\u05e2\u05dc\u05d0\u05d4\/\u05d2\u05e8\u05d5\u05e8 \u05d0\u05ea \u05d4\u05ea\u05de\u05d5\u05e0\u05d4<\/div>\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<input type=\"file\" accept=\"image\/*\" id=\"upload_left_bite\" name=\"oral_photos[left_bite]\" class=\"d-none cs-face-photo-input\" data-target-preview=\"left_bite\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mt-1 small text-center\">\u05e0\u05e9\u05d9\u05db\u05d4 \u05e9\u05de\u05d0\u05dc\u05d9\u05ea<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<!-- OralPhoto row end here -->\n\n\t\t\t<!-- X-rays Photos row start here -->\n\t\t\t<div class=\"mb-4\">\n\t\t\t\t<div class=\"fw-semibold mb-2\">\u05e6\u05d9\u05dc\u05d5\u05de\u05d9 \u05e8\u05e0\u05d8\u05d2\u05df<\/div>\n\t\t\t\t<div class=\"row g-3\">\n\t\t\t\t\t<div class=\"col-md-4\">\n\t\t\t\t\t\t<div class=\"position-relative border rounded image-upload-wrapper\">\n\t\t\t\t\t\t\t<label for=\"upload_panorama\" class=\"w-100 h-100 m-0 d-flex flex-column align-items-center justify-content-center text-center\">\n\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/orthodontist.clear-smile.co.il\/wp-content\/plugins\/clear-smile-orthodontist-case-system\/\/assets\/images\/xrays\/panorama.png\" alt=\"\u05e4\u05e0\u05d5\u05e8\u05de\u05d4\" class=\"img-fluid\" id=\"panorama_preview\">\n\t\t\t\t\t\t\t\t<div class=\"mt-1 small\">\u05dc\u05d7\u05e5 \u05dc\u05d4\u05e2\u05dc\u05d0\u05d4\/\u05d2\u05e8\u05d5\u05e8 \u05d0\u05ea \u05d4\u05ea\u05de\u05d5\u05e0\u05d4<\/div>\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<input type=\"file\" accept=\"image\/*\" id=\"upload_panorama\" name=\"xray_photos[panorama]\" class=\"d-none cs-face-photo-input\" data-target-preview=\"panorama\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mt-1 small text-center\">\u05e4\u05e0\u05d5\u05e8\u05de\u05d4<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"col-md-4\">\n\t\t\t\t\t\t<div class=\"position-relative border rounded image-upload-wrapper\">\n\t\t\t\t\t\t\t<label for=\"upload_lateral_sheet\" class=\"w-100 h-100 m-0 d-flex flex-column align-items-center justify-content-center text-center\">\n\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/orthodontist.clear-smile.co.il\/wp-content\/plugins\/clear-smile-orthodontist-case-system\/\/assets\/images\/xrays\/lateral_sheet.png\" alt=\"\u05e6\u05d9\u05dc\u05d5\u05dd \u05e6\u05d3\" class=\"img-fluid\" id=\"lateral_sheet_preview\">\n\t\t\t\t\t\t\t\t<div class=\"mt-1 small\">\u05dc\u05d7\u05e5 \u05dc\u05d4\u05e2\u05dc\u05d0\u05d4\/\u05d2\u05e8\u05d5\u05e8 \u05d0\u05ea \u05d4\u05ea\u05de\u05d5\u05e0\u05d4<\/div>\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<input type=\"file\" accept=\"image\/*\" id=\"upload_lateral_sheet\" name=\"xray_photos[lateral_sheet]\" class=\"d-none cs-face-photo-input\" data-target-preview=\"lateral_sheet\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mt-1 small text-center\">\u05e6\u05d9\u05dc\u05d5\u05dd \u05e6\u05d3<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<!-- X-rays Photos row end here -->\n\n\t\t\t<!-- other video materials row start here -->\n\t\t\t<div class=\"mb-4\">\n\t\t\t\t<div class=\"fw-semibold mb-2\">\u05d7\u05d5\u05de\u05e8\u05d9 \u05d5\u05d9\u05d3\u05d0\u05d5 \u05d0\u05d7\u05e8\u05d9\u05dd<\/div>\n\t\t\t\t<div class=\"row g-3\">\n\t\t\t\t\t<div class=\"col-md-4\">\n\t\t\t\t\t\t<div class=\"position-relative border rounded image-upload-wrapper\">\n\t\t\t\t\t\t\t<label for=\"other_video_materials\" class=\"w-100 h-100 m-0 d-flex flex-column align-items-center justify-content-center text-center\">\n\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/orthodontist.clear-smile.co.il\/wp-content\/plugins\/clear-smile-orthodontist-case-system\/\/assets\/images\/placeholder.png\" alt=\"\u05e6\u05d9\u05dc\u05d5\u05dd \u05e6\u05d3\" class=\"img-fluid\" id=\"other_video_materials_preview\">\n\t\t\t\t\t\t\t\t<div class=\"mt-1 small\">\u05dc\u05d7\u05e5 \u05dc\u05d4\u05e2\u05dc\u05d0\u05d4\/\u05d2\u05e8\u05d5\u05e8 \u05d0\u05ea \u05d4\u05ea\u05de\u05d5\u05e0\u05d4<\/div>\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<input type=\"file\" accept=\"image\/*\" id=\"other_video_materials\" name=\"other_video_materials\" class=\"d-none cs-face-photo-input\" data-target-preview=\"other_video_materials\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t<div class=\"mb-4\">\n\t\t\t\t<h3>\u05de\u05d5\u05d3\u05dc \u05d3\u05e0\u05d8\u05dc\u05d9<\/h3>\n\t\t\t\t<p>\u05d0\u05e0\u05d0 \u05d4\u05e2\u05dc\u05d4 \u05d0\u05ea \u05d4\u05de\u05d5\u05d3\u05dc \u05d4\u05d3\u05d9\u05d2\u05d9\u05d8\u05dc\u05d9 \u05d0\u05d5 \u05de\u05dc\u05d0 \u05d0\u05ea \u05e4\u05e8\u05d8\u05d9 \u05de\u05e9\u05dc\u05d5\u05d7 \u05de\u05d5\u05d3\u05dc \u05d4\u05e1\u05d9\u05dc\u05d9\u05e7\u05d5\u05df<\/p>\n\t\t\t<\/div>\n\t\t\t<!-- Digital model row start here -->\n\t\t\t<div class=\"mb-4\">\n\t\t\t\t<h5 class=\"mb-2\">\u05de\u05d5\u05d3\u05dc \u05d3\u05d9\u05d2\u05d9\u05d8\u05dc\u05d9<\/h5>\n\t\t\t\t<div class=\"row g-3\">\n\t\t\t\t\t<div class=\"col-md-4\">\n\t\t\t\t\t\t<div class=\"position-relative border rounded image-upload-wrapper\">\n\t\t\t\t\t\t\t<label for=\"upload_upper_model\" class=\"w-100 h-100 m-0 d-flex flex-column align-items-center justify-content-center text-center\">\n\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/orthodontist.clear-smile.co.il\/wp-content\/plugins\/clear-smile-orthodontist-case-system\/assets\/images\/models\/upper.png\" alt=\"\u05de\u05d5\u05d3\u05dc \u05e9\u05df \u05e2\u05dc\u05d9\u05d5\u05e0\u05d4\" class=\"img-fluid\" id=\"upper_model_preview\">\n\t\t\t\t\t\t\t\t<div class=\"mt-1 small\">\u05dc\u05d7\u05e5 \u05dc\u05d4\u05e2\u05dc\u05d0\u05d4\/\u05d2\u05e8\u05d5\u05e8 \u05d0\u05ea \u05d4\u05ea\u05de\u05d5\u05e0\u05d4<\/div>\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<input type=\"file\" accept=\"image\/*\" id=\"upload_upper_model\" name=\"digital_models[upper_model]\" class=\"d-none cs-face-photo-input\" data-target-preview=\"upper_model\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mt-1 small text-center\">\u05de\u05d5\u05d3\u05dc \u05e9\u05df \u05e2\u05dc\u05d9\u05d5\u05e0\u05d4<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"col-md-4\">\n\t\t\t\t\t\t<div class=\"position-relative border rounded image-upload-wrapper\">\n\t\t\t\t\t\t\t<label for=\"upload_lower_model\" class=\"w-100 h-100 m-0 d-flex flex-column align-items-center justify-content-center text-center\">\n\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/orthodontist.clear-smile.co.il\/wp-content\/plugins\/clear-smile-orthodontist-case-system\/assets\/images\/models\/lower.png\" alt=\"\u05de\u05d5\u05d3\u05dc \u05e9\u05d9\u05e0\u05d9\u05d9\u05dd \u05ea\u05d7\u05ea\u05d5\u05e0\u05d5\u05ea\" class=\"img-fluid\" id=\"lower_model_preview\">\n\t\t\t\t\t\t\t\t<div class=\"mt-1 small\">\u05dc\u05d7\u05e5 \u05dc\u05d4\u05e2\u05dc\u05d0\u05d4\/\u05d2\u05e8\u05d5\u05e8 \u05d0\u05ea \u05d4\u05ea\u05de\u05d5\u05e0\u05d4<\/div>\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<input type=\"file\" accept=\"image\/*\" id=\"upload_lower_model\" name=\"digital_models[lower_model]\" class=\"d-none cs-face-photo-input\" data-target-preview=\"lower_model\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mt-1 small text-center\">\u05de\u05d5\u05d3\u05dc \u05e9\u05d9\u05e0\u05d9\u05d9\u05dd \u05ea\u05d7\u05ea\u05d5\u05e0\u05d5\u05ea<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"col-md-4\"><!-- empty column --><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"row g-3 mt-3\">\n\t\t\t\t\t<div class=\"col-md-8\">\n\t\t\t\t\t\t<div class=\"position-relative border rounded image-upload-wrapper\">\n\t\t\t\t\t\t\t<label for=\"upload_occlusal_model\" class=\"w-100 h-100 m-0 d-flex flex-column align-items-center justify-content-center text-center\">\n\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/orthodontist.clear-smile.co.il\/wp-content\/plugins\/clear-smile-orthodontist-case-system\/assets\/images\/models\/occlusal.png\" alt=\"\u05de\u05d5\u05d3\u05dc \u05e1\u05d2\u05e8\" class=\"img-fluid\" id=\"occlusal_model_preview\">\n\t\t\t\t\t\t\t\t<div class=\"mt-1 small\">\u05dc\u05d7\u05e5 \u05dc\u05d4\u05e2\u05dc\u05d0\u05d4\/\u05d2\u05e8\u05d5\u05e8 \u05d0\u05ea \u05d4\u05ea\u05de\u05d5\u05e0\u05d4<\/div>\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<input type=\"file\" accept=\"image\/*\" id=\"upload_occlusal_model\" name=\"digital_models[occlusal_model]\" class=\"d-none cs-face-photo-input\" data-target-preview=\"occlusal_model\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mt-1 small text-center\">\u05de\u05d5\u05d3\u05dc \u05e1\u05d2\u05e8<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"col-md-4\"><!-- empty column --><\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<!-- Digital model row end here -->\n\n\t\t\t<!--- CBCT data start here --->\n\t\t\t<div class=\"mb-4\">\n\t\t\t\t<div class=\"row\">\n\t\t\t\t\t<div class=\"col-md-6\"> \n\t\t\t\t\t\t<div class=\"fw-semibold mb-2\">\u05e0\u05ea\u05d5\u05e0\u05d9 CBCT <span class=\"text-danger small\">(\u05e4\u05d5\u05e8\u05de\u05d8 rar, zip)<\/span><\/div>\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div id=\"cbct-data-wrapper\" class=\"position-relative border rounded image-upload-wrapper file-upload-wrapper\"> \n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t<label for=\"upload_cbct_data\" class=\"w-100 h-100 m-0 d-flex flex-column align-items-center justify-content-center text-center\">\n\t\t\t\t\t\t\t\t<i class=\"fas fa-file-archive\" style=\"font-size: 3rem; color: #6c757d;\"><\/i> \n\t\t\t\t\t\t\t\t<div class=\"mt-2 small\">\u05dc\u05d7\u05e5 \u05d0\u05d5 \u05d2\u05e8\u05d5\u05e8 \u05e7\u05d5\u05d1\u05e5 \u05dc\u05db\u05d0\u05df<\/div>\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t<input type=\"file\" accept=\".rar,.zip\" id=\"upload_cbct_data\" name=\"cbct_data\" class=\"d-none cs-face-photo-input\" data-target-preview=\"cbct_data\"> \n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t<div class=\"file-link-container\" style=\"display: none; position: absolute; top: 0; left: 0; right: 0; bottom: 0; background: #f8fafc; padding: 1rem; align-items: center; justify-content: center;\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<!--- CBCT data end here --->\n\n\t\t\t<!--- Other annexes start here --->\n\t\t\t<div class=\"mb-4\">\n\t\t\t\t<div class=\"row\">\n\t\t\t\t\t<div class=\"col-md-6\">\n\t\t\t\t\t\t<label for=\"upload_other_annexes\" class=\"form-label fw-semibold\">\u05e0\u05e1\u05e4\u05d7\u05d9\u05dd \u05d0\u05d7\u05e8\u05d9\u05dd<\/label>\n\t\t\t\t\t\t\n\t\t\t\t\t\t<input class=\"form-control\" type=\"file\" id=\"upload_other_annexes\" name=\"other_annexes\" data-target-preview=\"other_annexes\">\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div id=\"other-annexes-file-list\" class=\"mt-2 list-group list-group-flush\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\n\t\t\t\t\t\t<p class=\"mt-1 small text-muted\">\u05d0\u05dd \u05d9\u05e9 \u05dc\u05da \u05de\u05d5\u05d3\u05dc\u05d9\u05dd \u05d3\u05d9\u05d2\u05d9\u05d8\u05dc\u05d9\u05d9\u05dd \u05d0\u05d7\u05e8\u05d9\u05dd \u05d0\u05d5 \u05e0\u05ea\u05d5\u05e0\u05d9\u05dd \u05d0\u05d7\u05e8\u05d9\u05dd, \u05ea\u05d5\u05db\u05dc \u05dc\u05d4\u05e2\u05dc\u05d5\u05ea \u05d0\u05d5\u05ea\u05dd \u05dc\u05de\u05d8\u05d4. \u05d4\u05e2\u05dc\u05d4 \u05e7\u05d1\u05e6\u05d9\u05dd \u05de\u05e8\u05d5\u05d1\u05d9\u05dd \u05d0\u05d7\u05d3 \u05d0\u05d7\u05e8\u05d9 \u05d4\u05e9\u05e0\u05d9.<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<!--- Other annexes end here --->\n\t\t<\/div>\n    <\/div>\n\t                        <div class=\"d-flex justify-content-between\">\n                            <button type=\"button\" class=\"btn btn-secondary text-white cs-previous-step\" data-step=\"1\">\u05e7\u05d5\u05d3\u05dd<\/button>\n                            <button type=\"button\" class=\"btn btn-primary cs-next-step btn-lg\" data-current-step=\"2\">\u05e9\u05dc\u05d1 \u05d4\u05d1\u05d0<\/button>\n                        <\/div>\n                    <\/div>\n\n                    <div class=\"cs-step-pane d-none\" data-step=\"3\">\n                        \t<h2>\u05d0\u05d1\u05d7\u05e0\u05d4 \u05e7\u05dc\u05d9\u05e0\u05d9\u05ea<\/h2>\n\n\t<!--- Correction Objectives start here --->\n\t<div class=\"mb-4 p-3 border rounded shadow-sm\">\n\t\t<h5 class=\"mb-3\">\u05d9\u05e2\u05d3\u05d9 \u05ea\u05d9\u05e7\u05d5\u05df<\/h5>\n\n\t\t<div class=\"mb-3\">\n\t\t\t<div class=\"form-label fw-semibold\">\u05d1\u05e2\u05d9\u05d5\u05ea \u05d3\u05e0\u05d8\u05dc\u05d9\u05d5\u05ea<\/div>\n\t\t\t<div class=\"d-flex flex-wrap gap-2\" role=\"group\" aria-label=\"\u05d9\u05e2\u05d3\u05d9 \u05ea\u05d9\u05e7\u05d5\u05df \u05d3\u05e0\u05d8\u05dc\u05d9\">\n\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"correction_dental[]\" id=\"co_align_teeth\" value=\"align_your_teeth\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"co_align_teeth\">\u05d9\u05d9\u05e9\u05e8 \u05d0\u05ea \u05d4\u05e9\u05d9\u05e0\u05d9\u05d9\u05dd<\/label>\n\n\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"correction_dental[]\" id=\"co_improve_protrusion\" value=\"improve_protrusion\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"co_improve_protrusion\">\u05e9\u05e4\u05e8 \u05d1\u05dc\u05d9\u05d8\u05d4<\/label>\n\n\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"correction_dental[]\" id=\"co_close_gap\" value=\"close_the_gap\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"co_close_gap\">\u05e1\u05d2\u05d5\u05e8 \u05d0\u05ea \u05d4\u05e8\u05d5\u05d5\u05d7<\/label>\n\n\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"correction_dental[]\" id=\"co_improves_bite\" value=\"improves_bite\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"co_improves_bite\">\u05de\u05e9\u05e4\u05e8 \u05e0\u05e9\u05d9\u05db\u05d4<\/label>\n\n\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"correction_dental[]\" id=\"co_correct_opening_closing\" value=\"correct_opening_and_closing\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"co_correct_opening_closing\">\u05ea\u05e7\u05df \u05d0\u05ea \u05d4\u05e4\u05ea\u05d9\u05d7\u05d4 \u05d5\u05d4\u05e1\u05d2\u05d9\u05e8\u05d4<\/label>\n\n\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"correction_dental[]\" id=\"co_correct_opposite\" value=\"correct_the_opposite\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"co_correct_opposite\">\u05ea\u05e7\u05df \u05d0\u05ea \u05d4\u05d4\u05d9\u05e4\u05da<\/label>\n\n\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"correction_dental[]\" id=\"co_other_dental_obj\" value=\"other\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"co_other_dental_obj\">\u05d0\u05d7\u05e8<\/label>\n\n\t\t\t\t<div class=\"mt-2 w-100\" id=\"co_other_dental_wrapper\" style=\"display:none;\">\n\t\t\t\t\t<input type=\"text\" id=\"co_other_dental_text\" name=\"correction_dental_other\" class=\"form-control\" placeholder=\"\u05d0\u05e0\u05d0 \u05e6\u05d9\u05d9\u05df \u05d0\u05d7\u05e8\">\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\n\t\t<div class=\"mb-3\">\n\t\t\t<div class=\"form-label fw-semibold\">\u05d1\u05e2\u05d9\u05d5\u05ea \u05dc\u05e1\u05ea<\/div>\n\t\t\t<div class=\"d-flex flex-wrap gap-2\" role=\"group\" aria-label=\"\u05d9\u05e2\u05d3\u05d9 \u05ea\u05d9\u05e7\u05d5\u05df \u05dc\u05e1\u05ea\">\n\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"correction_jaw[]\" id=\"co_improve_maxillary\" value=\"improves_maxillary_protrusion\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"co_improve_maxillary\">\u05de\u05e9\u05e4\u05e8 \u05d1\u05dc\u05d9\u05d8\u05ea \u05dc\u05e1\u05ea \u05e2\u05dc\u05d9\u05d5\u05e0\u05d4<\/label>\n\n\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"correction_jaw[]\" id=\"co_improve_bimaxillary\" value=\"improves_bimaxillary_protrusion\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"co_improve_bimaxillary\">\u05de\u05e9\u05e4\u05e8 \u05d1\u05dc\u05d9\u05d8\u05d4 \u05d3\u05d5-\u05dc\u05e1\u05ea\u05d9\u05ea<\/label>\n\n\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"correction_jaw[]\" id=\"co_reverse_rotation\" value=\"reverse_rotation_of_the_jaw_improves_mandibular_retraction\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"co_reverse_rotation\">\u05e1\u05d9\u05d1\u05d5\u05d1 \u05d4\u05e4\u05d5\u05da \u05e9\u05dc \u05d4\u05dc\u05e1\u05ea \u05de\u05e9\u05e4\u05e8 \u05e0\u05e1\u05d9\u05d2\u05ea \u05d4\u05dc\u05e1\u05ea \u05d4\u05ea\u05d7\u05ea\u05d5\u05e0\u05d4<\/label>\n\n\t\t\t\t<input type=\"checkbox\" class=\"btn-check\" name=\"correction_jaw[]\" id=\"co_other_jaw_obj\" value=\"other\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"co_other_jaw_obj\">\u05d0\u05d7\u05e8<\/label>\n\n\t\t\t\t<div class=\"mt-2 w-100\" id=\"co_other_jaw_wrapper\" style=\"display:none;\">\n\t\t\t\t\t<input type=\"text\" id=\"co_other_jaw_text\" name=\"correction_jaw_other\" class=\"form-control\" placeholder=\"\u05d0\u05e0\u05d0 \u05e6\u05d9\u05d9\u05df \u05d0\u05d7\u05e8\">\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<!--- Correction Objectives end here --->\n\n\n\t<!--- Dental Information starts here --->\n\t<div class=\"mb-4 p-3 border rounded shadow-sm\">\n\t\t<h5 class=\"mb-3\">\u05de\u05d9\u05d3\u05e2 \u05d3\u05e0\u05d8\u05dc\u05d9<\/h5>\n\t\t<p class=\"small text-muted\">\u05d1\u05e8\u05d9\u05e8\u05ea \u05d4\u05de\u05d7\u05d3\u05dc \u05d4\u05d9\u05d0 \u05e9\u05db\u05dc \u05d4\u05e9\u05d9\u05e0\u05d9\u05d9\u05dd \u05d1\u05e7\u05e2\u05d5, \u05d0\u05e0\u05d0 \u05e1\u05de\u05df \u05d1\u05de\u05d3\u05d5\u05d9\u05e7 \u05d0\u05ea \u05d4\u05e9\u05d9\u05e0\u05d9\u05d9\u05dd \u05d4\u05d7\u05e1\u05e8\u05d5\u05ea \u05d5\u05e9\u05d9\u05e0\u05d9 \u05d4\u05d7\u05dc\u05d1 \u05d1\u05e9\u05d9\u05e0\u05d9\u05d9\u05dd<\/p>\n\n\t\t<div class=\"dental-information-block\">\n            <!-- First row -->\n            <div class=\"row\">\n                <div class=\"col-md-6 pb-2 justify-content-end d-flex flex-wrap border-end border-1 end-border-style-dashed\">\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_55\" value=\"55\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_55\">55<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_54\" value=\"54\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_54\">54<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_53\" value=\"53\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_53\">53<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_52\" value=\"52\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_52\">52<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_51\" value=\"51\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_51\">51<\/label>\n                                    <\/div>\n                <div class=\"col-md-6 d-flex flex-wrap pb-2\">\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_61\" value=\"61\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_61\">61<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_62\" value=\"62\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_62\">62<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_63\" value=\"63\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_63\">63<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_64\" value=\"64\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_64\">64<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_65\" value=\"65\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_65\">65<\/label>\n                                    <\/div>\n            <\/div>\n            <!-- Second row -->\n            <div class=\"row border-1 border-bottom bottom-border-style-dashed\">\n                <div class=\"col-md-6 pb-2 justify-content-end d-flex flex-wrap border-end border-1 end-border-style-dashed\">\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_18\" value=\"18\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_18\">18<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_17\" value=\"17\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_17\">17<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_16\" value=\"16\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_16\">16<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_15\" value=\"15\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_15\">15<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_14\" value=\"14\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_14\">14<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_13\" value=\"13\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_13\">13<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_12\" value=\"12\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_12\">12<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_11\" value=\"11\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_11\">11<\/label>\n                                    <\/div>\n                <div class=\"col-md-6 d-flex flex-wrap pb-2\">\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_21\" value=\"21\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_21\">21<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_22\" value=\"22\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_22\">22<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_23\" value=\"23\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_23\">23<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_24\" value=\"24\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_24\">24<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_25\" value=\"25\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_25\">25<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_26\" value=\"26\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_26\">26<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_27\" value=\"27\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_27\">27<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_28\" value=\"28\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_28\">28<\/label>\n                                    <\/div>\n            <\/div>\n            <!-- Third row -->\n            <div class=\"row\">\n                <div class=\"col-md-6 pt-2 pb-2 justify-content-end d-flex flex-wrap border-end border-1 end-border-style-dashed\">\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_48\" value=\"48\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_48\">48<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_47\" value=\"47\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_47\">47<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_46\" value=\"46\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_46\">46<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_45\" value=\"45\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_45\">45<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_44\" value=\"44\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_44\">44<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_43\" value=\"43\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_43\">43<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_42\" value=\"42\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_42\">42<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_41\" value=\"41\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_41\">41<\/label>\n                                    <\/div>\n                <div class=\"col-md-6 pt-2 d-flex flex-wrap pb-2\">\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_31\" value=\"31\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_31\">31<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_32\" value=\"32\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_32\">32<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_33\" value=\"33\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_33\">33<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_34\" value=\"34\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_34\">34<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_35\" value=\"35\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_35\">35<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_36\" value=\"36\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_36\">36<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_37\" value=\"37\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_37\">37<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_38\" value=\"38\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_38\">38<\/label>\n                                    <\/div>\n            <\/div>\n            <!-- Fourth row -->\n            <div class=\"row\">\n                <div class=\"col-md-6 pb-2 justify-content-end d-flex flex-wrap border-end border-1 end-border-style-dashed\">\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_85\" value=\"85\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_85\">85<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_84\" value=\"84\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_84\">84<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_83\" value=\"83\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_83\">83<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_82\" value=\"82\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_82\">82<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_81\" value=\"81\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_81\">81<\/label>\n                                    <\/div>\n                <div class=\"col-md-6 d-flex flex-wrap pb-2\">\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_71\" value=\"71\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_71\">71<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_72\" value=\"72\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_72\">72<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_73\" value=\"73\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_73\">73<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_74\" value=\"74\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_74\">74<\/label>\n                                            <input type=\"checkbox\" class=\"btn-check\" name=\"dental_info_teeth[]\" id=\"teeth_75\" value=\"75\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn\" for=\"teeth_75\">75<\/label>\n                                    <\/div>\n            <\/div>\n        <\/div>\n\t<\/div>\n\t<!--- Dental Information end here --->\n\n\t<!--- molar relationship start here --->\n\t<div class=\"mb-4 p-3 border rounded shadow-sm\">\n\t\t<h5 class=\"mb-3\">\u05db\u05e2\u05ea \u05d9\u05d7\u05e1\u05d9 \u05d4\u05d8\u05d5\u05d7\u05e0\u05d5\u05ea \u05d4\u05de\u05d7\u05d5\u05d3\u05d3\u05d5\u05ea<\/h5>\n\n\t\t<div class=\"mb-3\">\n\t\t\t<div class=\"form-label fw-semibold\">\u05e1\u05d9\u05d5\u05d5\u05d2 \u05d0\u05df - \u05d8\u05d5\u05d7\u05e0\u05d5\u05ea<\/div>\n\t\t\t<div class=\"\" role=\"group\" aria-label=\"\u05e1\u05d9\u05d5\u05d5\u05d2 \u05d8\u05d5\u05d7\u05e0\u05d5\u05ea\">\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"molar_classification\" id=\"molar_up_in_air\" value=\"up_in_the_air\" autocomplete=\"off\" required checked>\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"molar_up_in_air\">\u05d1\u05d0\u05d5\u05d5\u05d9\u05e8<\/label>\n\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"molar_classification\" id=\"molar_class_i\" value=\"class_i\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"molar_class_i\">\u05db\u05d9\u05ea\u05d4 I<\/label>\n\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"molar_classification\" id=\"molar_class_ii\" value=\"class_ii\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"molar_class_ii\">\u05db\u05d9\u05ea\u05d4 II<\/label>\n\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"molar_classification\" id=\"molar_class_iii\" value=\"class_iii\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice\" for=\"molar_class_iii\">\u05db\u05d9\u05ea\u05d4 III<\/label>\n\t\t\t<\/div>\n\t\t<\/div>\n\n\t\t<div class=\"mb-3\">\n\t\t\t<div class=\"form-label fw-semibold\">\u05e1\u05d9\u05d5\u05d5\u05d2 \u05d0\u05df - \u05e0\u05d9\u05d1\u05d9\u05dd<\/div>\n\t\t\t<div class=\"\" role=\"group\" aria-label=\"\u05e1\u05d9\u05d5\u05d5\u05d2 \u05e0\u05d9\u05d1\u05d9\u05dd\">\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"canine_classification\" id=\"canine_up_in_air\" value=\"up_in_the_air\" autocomplete=\"off\" required checked>\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"canine_up_in_air\">\u05d1\u05d0\u05d5\u05d5\u05d9\u05e8<\/label>\n\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"canine_classification\" id=\"canine_class_i\" value=\"class_i\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"canine_class_i\">\u05db\u05d9\u05ea\u05d4 I<\/label>\n\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"canine_classification\" id=\"canine_class_ii\" value=\"class_ii\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"canine_class_ii\">\u05db\u05d9\u05ea\u05d4 II<\/label>\n\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"canine_classification\" id=\"canine_class_iii\" value=\"class_iii\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice\" for=\"canine_class_iii\">\u05db\u05d9\u05ea\u05d4 III<\/label>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<!--- molar relationship end here --->\n\n\t<!--- Bone classification start here --->\n\t<div class=\"mb-4 p-3 border rounded shadow-sm\">\n\t\t<h5 class=\"mb-3\">\u05e1\u05d9\u05d5\u05d5\u05d2 \u05e2\u05e6\u05dd<\/h5>\n\n\t\t<div class=\"mb-3\">\n\t\t\t<div class=\"form-label fw-semibold\">\u05e1\u05d9\u05d5\u05d5\u05d2 \u05e2\u05e6\u05dd<\/div>\n\t\t\t<div class=\"\" role=\"group\" aria-label=\"\u05e1\u05d9\u05d5\u05d5\u05d2 \u05e2\u05e6\u05dd\">\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"bone_classification\" id=\"bone_up_in_air\" value=\"up_in_the_air\" autocomplete=\"off\" required checked>\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"bone_up_in_air\">\u05d1\u05d0\u05d5\u05d5\u05d9\u05e8<\/label>\n\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"bone_classification\" id=\"bone_type_i\" value=\"bone_type_i\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"bone_type_i\">\u05e2\u05e6\u05dd \u05e1\u05d5\u05d2 I<\/label>\n\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"bone_classification\" id=\"bone_type_ii\" value=\"bone_type_ii\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"bone_type_ii\">\u05e2\u05e6\u05dd \u05e1\u05d5\u05d2 II<\/label>\n\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"bone_classification\" id=\"bone_type_iii\" value=\"bone_type_iii\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice\" for=\"bone_type_iii\">\u05e2\u05e6\u05dd \u05e1\u05d5\u05d2 III<\/label>\n\t\t\t<\/div>\n\t\t<\/div>\n\n\t\t<div class=\"mb-3\">\n\t\t\t<div class=\"form-label fw-semibold\">\u05e1\u05d9\u05d5\u05d5\u05d2 \u05d0\u05e0\u05db\u05d9 \u05e9\u05dc \u05d8\u05d1\u05e2 \u05e2\u05e6\u05de\u05d9<\/div>\n\t\t\t<div class=\"\" role=\"group\" aria-label=\"\u05e1\u05d9\u05d5\u05d5\u05d2 \u05e2\u05e6\u05dd \u05d0\u05e0\u05db\u05d9\">\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"vertical_bone_classification\" id=\"vertical_up_in_air\" value=\"up_in_the_air\" autocomplete=\"off\" required checked>\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"vertical_up_in_air\">\u05d1\u05d0\u05d5\u05d5\u05d9\u05e8<\/label>\n\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"vertical_bone_classification\" id=\"vertical_low_angle\" value=\"low_angle\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"vertical_low_angle\">\u05d6\u05d5\u05d5\u05d9\u05ea \u05e0\u05de\u05d5\u05db\u05d4<\/label>\n\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"vertical_bone_classification\" id=\"vertical_equal_angle\" value=\"equal_angle\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice me-2\" for=\"vertical_equal_angle\">\u05d6\u05d5\u05d5\u05d9\u05ea \u05e9\u05d5\u05d5\u05d4<\/label>\n\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"vertical_bone_classification\" id=\"vertical_high_angle\" value=\"high_angle\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice\" for=\"vertical_high_angle\">\u05d6\u05d5\u05d5\u05d9\u05ea \u05d2\u05d1\u05d5\u05d4\u05d4<\/label>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<!--- Bone classification end here --->\n\t                        <div class=\"d-flex justify-content-between\">\n                            <button type=\"button\" class=\"btn btn-secondary text-white cs-previous-step\" data-step=\"2\">\u05e7\u05d5\u05d3\u05dd<\/button>\n                            <button type=\"button\" class=\"btn btn-primary cs-next-step btn-lg\" data-current-step=\"3\">\u05e9\u05dc\u05d1 \u05d4\u05d1\u05d0<\/button>\n                        <\/div>\n                    <\/div>\n\n                    <div class=\"cs-step-pane d-none\" data-step=\"4\">\n                        \t<h2>\u05d4\u05d2\u05d3\u05e8\u05d5\u05ea \u05d9\u05d9\u05e9\u05d5\u05e8<\/h2>\n\t<!---- Aligner settings start ---->\n\t<div class=\"mb-4 p-3 border rounded shadow-sm\">\n\t\t<h5 class=\"mb-3\">\u05dc\u05e1\u05ea\u05d5\u05ea \u05d0\u05d5\u05e8\u05ea\u05d5\u05d3\u05d5\u05e0\u05d8\u05d9\u05d5\u05ea<\/h5>\n\t\t<p class=\"small text-muted\">\u05e2\u05d1\u05d5\u05e8 \u05d0\u05d5\u05e8\u05ea\u05d5\u05d3\u05d5\u05e0\u05d8\u05d9\u05d4 \u05d7\u05d3-\u05dc\u05e1\u05ea\u05d9\u05ea, \u05d9\u05e9 \u05e6\u05d5\u05e8\u05da \u05d2\u05dd \u05dc\u05d4\u05d2\u05d9\u05e9 \u05de\u05d5\u05d3\u05dc \u05d3\u05d9\u05d2\u05d9\u05d8\u05dc\u05d9 \u05e9\u05dc \u05db\u05dc \u05d4\u05dc\u05e1\u05ea \u05d0\u05d5 \u05d4\u05d3\u05e4\u05e1\u05d9 \u05d2\u05d5\u05de\u05d9 \u05e1\u05d9\u05dc\u05d9\u05e7\u05d5\u05df<\/p>\n\t\t<div class=\"mb-4\" role=\"group\" aria-label=\"\u05dc\u05e1\u05ea\u05d5\u05ea \u05d0\u05d5\u05e8\u05ea\u05d5\u05d3\u05d5\u05e0\u05d8\u05d9\u05d5\u05ea\">\n\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"ortho_jaws\" id=\"ortho_full_jaw\" value=\"full_jaw\" autocomplete=\"off\" checked>\n\t\t\t<label class=\"btn btn-choice me-2\" for=\"ortho_full_jaw\">\u05dc\u05e1\u05ea \u05de\u05dc\u05d0\u05d4<\/label>\n\n\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"ortho_jaws\" id=\"ortho_maxillary\" value=\"maxillary\" autocomplete=\"off\">\n\t\t\t<label class=\"btn btn-choice me-2\" for=\"ortho_maxillary\">\u05dc\u05e1\u05ea \u05e2\u05dc\u05d9\u05d5\u05e0\u05d4<\/label>\n\n\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"ortho_jaws\" id=\"ortho_mandible\" value=\"mandible\" autocomplete=\"off\">\n\t\t\t<label class=\"btn btn-choice\" for=\"ortho_mandible\">\u05dc\u05e1\u05ea \u05ea\u05d7\u05ea\u05d5\u05e0\u05d4<\/label>\n\t\t<\/div>\n\n\t\t<h5 class=\"mb-3\">\u05e1\u05d5\u05d2\u05d9 \u05d0\u05d5\u05e8\u05ea\u05d5\u05d3\u05d5\u05e0\u05d8\u05d9\u05d4<\/h5>\n\t\t<p class=\"small text-muted\">\u05d0\u05d5\u05e8\u05ea\u05d5\u05d3\u05d5\u05e0\u05d8\u05d9\u05d4 \u05e7\u05d5\u05e0\u05d1\u05e0\u05e6\u05d9\u05d5\u05e0\u05dc\u05d9\u05ea \u05de\u05ea\u05d9\u05d9\u05d7\u05e1\u05ea \u05dc\u05e9\u05d9\u05de\u05d5\u05e9 \u05d1\u05d0\u05d5\u05ea\u05d5 \u05e1\u05d5\u05d2 \u05e9\u05dc \u05de\u05d9\u05d9\u05e9\u05e8\u05d9\u05dd \u05e2\u05d1\u05d5\u05e8 \u05d4\u05dc\u05e1\u05ea\u05d5\u05ea \u05d4\u05e2\u05dc\u05d9\u05d5\u05e0\u05d4 \u05d5\u05d4\u05ea\u05d7\u05ea\u05d5\u05e0\u05d4, \u05d5\u05d8\u05d9\u05e4\u05d5\u05dc \u05d0\u05d5\u05e8\u05ea\u05d5\u05d3\u05d5\u05e0\u05d8\u05d9 \u05de\u05e9\u05d5\u05dc\u05d1 \u05de\u05ea\u05d9\u05d9\u05d7\u05e1 \u05dc\u05e9\u05d9\u05de\u05d5\u05e9 \u05d1\u05de\u05d9\u05d9\u05e9\u05e8\u05d9\u05dd \u05e9\u05d5\u05e0\u05d9\u05dd \u05e2\u05d1\u05d5\u05e8 \u05d4\u05dc\u05e1\u05ea\u05d5\u05ea \u05d4\u05e2\u05dc\u05d9\u05d5\u05e0\u05d4 \u05d5\u05d4\u05ea\u05d7\u05ea\u05d5\u05e0\u05d4 (\u05d9\u05e9 \u05dc\u05d4\u05d2\u05d3\u05d9\u05e8 \u05ea\u05d5\u05db\u05e0\u05d9\u05d5\u05ea \u05de\u05d9\u05d9\u05e9\u05e8\u05d9\u05dd \u05e0\u05e4\u05e8\u05d3\u05d5\u05ea \u05e2\u05d1\u05d5\u05e8 \u05d4\u05dc\u05e1\u05ea\u05d5\u05ea \u05d4\u05e2\u05dc\u05d9\u05d5\u05e0\u05d4 \u05d5\u05d4\u05ea\u05d7\u05ea\u05d5\u05e0\u05d4 \u05d1\u05e0\u05e4\u05e8\u05d3)<\/p>\n\t\t<div class=\"btn-group mb-4\" role=\"group\" aria-label=\"\u05e1\u05d5\u05d2\u05d9 \u05d0\u05d5\u05e8\u05ea\u05d5\u05d3\u05d5\u05e0\u05d8\u05d9\u05d4\">\n\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"ortho_types\" id=\"ortho_routine_correction\" value=\"routine_correction\" autocomplete=\"off\" checked>\n\t\t\t<label class=\"btn btn-choice rounded\" for=\"ortho_routine_correction\">\u05ea\u05d9\u05e7\u05d5\u05df \u05e9\u05d2\u05e8\u05ea\u05d9<\/label>\n\t\t<\/div>\n\n\t\t<h5 class=\"mb-3\">\u05d0\u05d5\u05e8\u05ea\u05d5\u05d3\u05d5\u05e0\u05d8\u05d9\u05d4 \u05e7\u05d5\u05e0\u05d1\u05e0\u05e6\u05d9\u05d5\u05e0\u05dc\u05d9\u05ea - \u05dc\u05e1\u05ea \u05de\u05dc\u05d0\u05d4<\/h5>\n\t\t<div class=\"mb-3\">\n\t\t\t<label class=\"form-label\">\u05e1\u05d5\u05d2 \u05de\u05d9\u05d9\u05e9\u05e8:<\/label>\n\t\t\t<div class=\"btn-group\" role=\"group\" aria-label=\"\u05e1\u05d5\u05d2 \u05de\u05d9\u05d9\u05e9\u05e8\">\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"aligner_type\" id=\"aligner_bracketless\" value=\"bracketless_invisible_aligners\" autocomplete=\"off\" checked>\n\t\t\t\t<label class=\"btn btn-choice rounded\" for=\"aligner_bracketless\">\u05de\u05d9\u05d9\u05e9\u05e8\u05d9\u05dd \u05d1\u05dc\u05ea\u05d9 \u05e0\u05e8\u05d0\u05d9\u05dd \u05dc\u05dc\u05d0 \u05e1\u05d5\u05d2\u05e8\u05d9\u05d9\u05dd<\/label>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<!---- Aligner settings end ---->\n\t                        <div class=\"d-flex justify-content-between\">\n                            <button type=\"button\" class=\"btn btn-secondary text-white cs-previous-step\" data-step=\"3\">\u05e7\u05d5\u05d3\u05dd<\/button>\n                            <button type=\"button\" class=\"btn btn-primary cs-next-step btn-lg\" data-current-step=\"4\">\u05e9\u05dc\u05d1 \u05d4\u05d1\u05d0<\/button>\n                        <\/div>\n                    <\/div>\n\n                    <div class=\"cs-step-pane d-none\" data-step=\"5\">\n                            <h2>\u05ea\u05db\u05e0\u05d5\u05df \u05de\u05d9\u05e7\u05d5\u05dd \u05d9\u05e2\u05d3<\/h2>\n\n    <!--- Not designed to move teeth start here --->\n    <div class=\"mb-4 p-3 border rounded shadow-sm\">\n        <h5 class=\"mb-3\">\u05dc\u05d0 \u05de\u05d9\u05d5\u05e2\u05d3 \u05dc\u05d4\u05d6\u05d9\u05d6 \u05e9\u05d9\u05e0\u05d9\u05d9\u05dd<\/h5>\n\n        <div class=\"mb-3\">\n            <div class=\"\" role=\"group\" aria-label=\"\u05d0\u05e4\u05e9\u05e8\u05d5\u05d9\u05d5\u05ea \u05dc\u05d0 \u05de\u05d9\u05d5\u05e2\u05d3\u05d5\u05ea\">\n                <input type=\"radio\" class=\"btn-check\" name=\"ndm_option\" id=\"ndm_not_moment\" value=\"not_at_the_moment\" autocomplete=\"off\" checked>\n                <label class=\"btn btn btn-choice me-2\" for=\"ndm_not_moment\">\u05dc\u05d0 \u05db\u05e8\u05d2\u05e2<\/label>\n\n                <input type=\"radio\" class=\"btn-check\" name=\"ndm_option\" id=\"ndm_following_teeth\" value=\"the_following_teeth_are_not_designed_to_move\" autocomplete=\"off\">\n                <label class=\"btn btn btn-choice\" for=\"ndm_following_teeth\">\u05d4\u05e9\u05d9\u05e0\u05d9\u05d9\u05dd \u05d4\u05d1\u05d0\u05d5\u05ea \u05d0\u05d9\u05e0\u05df \u05de\u05d9\u05d5\u05e2\u05d3\u05d5\u05ea \u05dc\u05ea\u05d6\u05d5\u05d6\u05d4<\/label>\n            <\/div>\n        <\/div>\n\n        <div id=\"ndm_teeth_wrapper\" style=\"display:none;\">\n            <p class=\"small text-muted\">\u05de\u05d9\u05e7\u05d5\u05de\u05d9 \u05d4\u05e9\u05d9\u05e0\u05d9\u05d9\u05dd \u05d4\u05de\u05d5\u05e6\u05d2\u05d9\u05dd \u05dc\u05d4\u05dc\u05df \u05d4\u05dd \u05d4\u05de\u05d9\u05e7\u05d5\u05de\u05d9\u05dd \u05d4\u05e7\u05d9\u05d9\u05de\u05d9\u05dd \u05e9\u05e0\u05e7\u05d1\u05e2\u05d5 \u05d1\u05de\u05d9\u05d3\u05e2 \u05e2\u05dc \u05de\u05d9\u05e7\u05d5\u05dd \u05d4\u05e9\u05d9\u05e0\u05d9\u05d9\u05dd \u05d1\u05d0\u05d1\u05d7\u05e0\u05d4 \u05d4\u05e7\u05dc\u05d9\u05e0\u05d9\u05ea; \u05d0\u05dd \u05de\u05d9\u05e7\u05d5\u05dd \u05d4\u05e9\u05df \u05d4\u05de\u05ea\u05d0\u05d9\u05dd \u05dc\u05d0 \u05e0\u05de\u05e6\u05d0 \u05dc\u05d4\u05dc\u05df, \u05d0\u05e0\u05d0 \u05e9\u05e0\u05d4 \u05d0\u05ea \u05de\u05d9\u05d3\u05e2 \u05de\u05d9\u05e7\u05d5\u05dd \u05d4\u05e9\u05df \u05d1\u05d0\u05d1\u05d7\u05e0\u05d4 \u05d4\u05e7\u05dc\u05d9\u05e0\u05d9\u05ea<\/p>\n            <!-- First row teeth -->\n            <div class=\"row\">\n                <div class=\"col-md-6 pb-2 justify-content-end d-flex flex-wrap border-end border-1 end-border-style-dashed\">\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_55\" value=\"55\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_55\">55<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_54\" value=\"54\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_54\">54<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_53\" value=\"53\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_53\">53<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_52\" value=\"52\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_52\">52<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_51\" value=\"51\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_51\">51<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                    <\/div>\n                <div class=\"col-md-6 d-flex flex-wrap pb-2\">\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_61\" value=\"61\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_61\">61<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_62\" value=\"62\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_62\">62<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_63\" value=\"63\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_63\">63<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_64\" value=\"64\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_64\">64<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_65\" value=\"65\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_65\">65<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                    <\/div>\n            <\/div>\n            <div class=\"row border-1 border-bottom bottom-border-style-dashed\">\n                <div class=\"col-md-6 pb-2 justify-content-end d-flex flex-wrap border-end border-1 end-border-style-dashed\">\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_18\" value=\"18\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_18\">18<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_17\" value=\"17\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_17\">17<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_16\" value=\"16\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_16\">16<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_15\" value=\"15\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_15\">15<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_14\" value=\"14\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_14\">14<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_13\" value=\"13\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_13\">13<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_12\" value=\"12\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_12\">12<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_11\" value=\"11\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_11\">11<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                    <\/div>\n                <div class=\"col-md-6 d-flex flex-wrap pb-2\">\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_21\" value=\"21\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_21\">21<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_22\" value=\"22\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_22\">22<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_23\" value=\"23\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_23\">23<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_24\" value=\"24\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_24\">24<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_25\" value=\"25\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_25\">25<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_26\" value=\"26\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_26\">26<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_27\" value=\"27\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_27\">27<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_28\" value=\"28\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_28\">28<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                    <\/div>\n            <\/div>\n            <div class=\"row\">\n                <div class=\"col-md-6 pt-2 pb-2 justify-content-end d-flex flex-wrap border-end border-1 end-border-style-dashed\">\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_48\" value=\"48\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_48\">48<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_47\" value=\"47\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_47\">47<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_46\" value=\"46\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_46\">46<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_45\" value=\"45\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_45\">45<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_44\" value=\"44\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_44\">44<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_43\" value=\"43\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_43\">43<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_42\" value=\"42\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_42\">42<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_41\" value=\"41\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_41\">41<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                    <\/div>\n                <div class=\"col-md-6 pt-2 d-flex flex-wrap pb-2\">\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_31\" value=\"31\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_31\">31<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_32\" value=\"32\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_32\">32<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_33\" value=\"33\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_33\">33<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_34\" value=\"34\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_34\">34<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_35\" value=\"35\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_35\">35<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_36\" value=\"36\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_36\">36<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_37\" value=\"37\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_37\">37<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_38\" value=\"38\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_38\">38<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                    <\/div>\n            <\/div>\n            <div class=\"row\">\n                <div class=\"col-md-6 pb-2 justify-content-end d-flex flex-wrap border-end border-1 end-border-style-dashed\">\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_85\" value=\"85\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_85\">85<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_84\" value=\"84\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_84\">84<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_83\" value=\"83\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_83\">83<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_82\" value=\"82\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_82\">82<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_81\" value=\"81\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_81\">81<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                    <\/div>\n                <div class=\"col-md-6 d-flex flex-wrap pb-2\">\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_71\" value=\"71\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_71\">71<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_72\" value=\"72\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_72\">72<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_73\" value=\"73\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_73\">73<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_74\" value=\"74\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_74\">74<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check ndm-tooth-checkbox\" name=\"ndm_teeth[]\" id=\"ndm_teeth_75\" value=\"75\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"ndm_teeth_75\">75<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                    <\/div>\n            <\/div>\n        <\/div>\n    <\/div>\n    <!--- Not designed to move teeth end here --->\n\n    <!--- Crowding is lifted (Tooth extraction) start here --->\n    <div class=\"mb-4 p-3 border rounded shadow-sm\">\n        <h5 class=\"mb-3\">\u05d4\u05e6\u05e4\u05d9\u05e4\u05d5\u05ea \u05d4\u05d5\u05e1\u05e8\u05d4 <span class=\"text-danger\">*<\/span><\/h5>\n        <p class=\"small text-muted\">\u05e2\u05e7\u05d9\u05e8\u05ea \u05e9\u05df<\/p>\n\n        <div class=\"mb-3\">\n            <div role=\"group\" aria-label=\"\u05e2\u05e7\u05d9\u05e8\u05ea \u05e9\u05df\">\n                <input type=\"radio\" class=\"btn-check\" name=\"te_extraction_option\" id=\"te_no_extraction\" value=\"no_teeth_extracted\" autocomplete=\"off\" checked>\n                <label class=\"btn btn btn-choice me-2\" for=\"te_no_extraction\">\u05dc\u05d0 \u05e0\u05e2\u05e7\u05e8\u05d5 \u05e9\u05d9\u05e0\u05d9\u05d9\u05dd<\/label>\n\n                <input type=\"radio\" class=\"btn-check\" name=\"te_extraction_option\" id=\"te_following_extraction\" value=\"the_following_teeth_are_removed\" autocomplete=\"off\">\n                <label class=\"btn btn btn-choice\" for=\"te_following_extraction\">\u05d4\u05e9\u05d9\u05e0\u05d9\u05d9\u05dd \u05d4\u05d1\u05d0\u05d5\u05ea \u05d4\u05d5\u05e1\u05e8\u05d5<\/label>\n            <\/div>\n        <\/div>\n\n        <div id=\"te_extraction_wrapper\" style=\"display:none;\">\n            <p class=\"small text-muted\">\n                \u05de\u05d9\u05e7\u05d5\u05de\u05d9 \u05d4\u05e9\u05d9\u05e0\u05d9\u05d9\u05dd \u05d4\u05de\u05d5\u05e6\u05d2\u05d9\u05dd \u05dc\u05d4\u05dc\u05df \u05d4\u05dd \u05d4\u05de\u05d9\u05e7\u05d5\u05de\u05d9\u05dd \u05d4\u05e7\u05d9\u05d9\u05de\u05d9\u05dd \u05e9\u05e0\u05e7\u05d1\u05e2\u05d5 \u05d1\u05d0\u05d1\u05d7\u05e0\u05d4 \u05d4\u05e7\u05dc\u05d9\u05e0\u05d9\u05ea; \u05d0\u05dd \u05e9\u05df \u05d7\u05e1\u05e8\u05d4 \u05de\u05e8\u05e9\u05d9\u05de\u05d4 \u05d6\u05d5, \u05d0\u05e0\u05d0 \u05e2\u05d3\u05db\u05df \u05ea\u05d7\u05d9\u05dc\u05d4 \u05d0\u05ea \u05e9\u05dc\u05d1 \u05d4\u05d0\u05d1\u05d7\u05e0\u05d4 \u05d4\u05e7\u05dc\u05d9\u05e0\u05d9\u05ea.            <\/p>\n            <!-- Row 1: upper quadrants -->\n            <div class=\"row\">\n                <div class=\"col-md-6 pb-2 justify-content-end d-flex flex-wrap border-end border-1 end-border-style-dashed\">\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_55\" value=\"55\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_55\">55<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_54\" value=\"54\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_54\">54<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_53\" value=\"53\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_53\">53<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_52\" value=\"52\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_52\">52<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_51\" value=\"51\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_51\">51<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                    <\/div>\n                <div class=\"col-md-6 d-flex flex-wrap pb-2\">\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_61\" value=\"61\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_61\">61<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_62\" value=\"62\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_62\">62<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_63\" value=\"63\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_63\">63<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_64\" value=\"64\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_64\">64<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_65\" value=\"65\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_65\">65<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                    <\/div>\n            <\/div>\n            <div class=\"row border-1 border-bottom bottom-border-style-dashed\">\n                <div class=\"col-md-6 pb-2 justify-content-end d-flex flex-wrap border-end border-1 end-border-style-dashed\">\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_18\" value=\"18\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_18\">18<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_17\" value=\"17\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_17\">17<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_16\" value=\"16\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_16\">16<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_15\" value=\"15\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_15\">15<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_14\" value=\"14\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_14\">14<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_13\" value=\"13\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_13\">13<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_12\" value=\"12\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_12\">12<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_11\" value=\"11\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_11\">11<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                    <\/div>\n                <div class=\"col-md-6 d-flex flex-wrap pb-2\">\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_21\" value=\"21\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_21\">21<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_22\" value=\"22\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_22\">22<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_23\" value=\"23\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_23\">23<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_24\" value=\"24\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_24\">24<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_25\" value=\"25\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_25\">25<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_26\" value=\"26\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_26\">26<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_27\" value=\"27\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_27\">27<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_28\" value=\"28\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_28\">28<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                    <\/div>\n            <\/div>\n            <div class=\"row\">\n                <div class=\"col-md-6 pt-2 pb-2 justify-content-end d-flex flex-wrap border-end border-1 end-border-style-dashed\">\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_48\" value=\"48\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_48\">48<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_47\" value=\"47\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_47\">47<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_46\" value=\"46\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_46\">46<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_45\" value=\"45\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_45\">45<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_44\" value=\"44\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_44\">44<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_43\" value=\"43\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_43\">43<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_42\" value=\"42\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_42\">42<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_41\" value=\"41\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_41\">41<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                    <\/div>\n                <div class=\"col-md-6 pt-2 d-flex flex-wrap pb-2\">\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_31\" value=\"31\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_31\">31<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_32\" value=\"32\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_32\">32<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_33\" value=\"33\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_33\">33<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_34\" value=\"34\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_34\">34<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_35\" value=\"35\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_35\">35<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_36\" value=\"36\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_36\">36<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_37\" value=\"37\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_37\">37<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_38\" value=\"38\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_38\">38<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                    <\/div>\n            <\/div>\n            <div class=\"row\">\n                <div class=\"col-md-6 pb-2 justify-content-end d-flex flex-wrap border-end border-1 end-border-style-dashed\">\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_85\" value=\"85\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_85\">85<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_84\" value=\"84\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_84\">84<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_83\" value=\"83\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_83\">83<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_82\" value=\"82\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_82\">82<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_81\" value=\"81\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_81\">81<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                    <\/div>\n                <div class=\"col-md-6 d-flex flex-wrap pb-2\">\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_71\" value=\"71\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_71\">71<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_72\" value=\"72\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_72\">72<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_73\" value=\"73\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_73\">73<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_74\" value=\"74\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_74\">74<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                            <div class=\"tooth-lock-container\">\n                            <input type=\"checkbox\" class=\"btn-check te-tooth-checkbox\" name=\"te_extraction_teeth[]\" id=\"te_ext_75\" value=\"75\" autocomplete=\"off\">\n                            <label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"te_ext_75\">75<\/label>\n                            <div class=\"tooth-lock-icon\"><\/div>\n                        <\/div>\n                                    <\/div>\n            <\/div>\n        <\/div>\n\n        <!-- Expand the bow start here -->\n        <div class=\"mt-4\">\n            <div class=\"form-label fw-semibold mb-2\">\u05d4\u05e8\u05d7\u05d1 \u05d0\u05ea \u05d4\u05e7\u05e9\u05ea<\/div>\n\n            <div class=\"row align-items-center mb-3\">\n                <div class=\"col-lg-2 col-md-12\">\n                    <span class=\"small\">\u05dc\u05e1\u05ea \u05e2\u05dc\u05d9\u05d5\u05e0\u05d4<\/span>\n                <\/div>\n                <div class=\"col-lg-10 col-md-12\">\n                    <div class=\"row align-items-center\">\n                        <div class=\"col-md-7 col-12\">\n                            <div class=\"d-flex flex-wrap gap-2\">\n                                <input type=\"radio\" class=\"btn-check\" name=\"expand_bow_maxillary\" id=\"eb_maxillary_no\" value=\"no\" autocomplete=\"off\" checked>\n                                <label class=\"btn btn-choice\" for=\"eb_maxillary_no\">\u05d0\u05dc \u05ea\u05e8\u05d7\u05d9\u05d1 \u05d0\u05ea \u05d4\u05e7\u05e9\u05ea<\/label>\n\n                                <input type=\"radio\" class=\"btn-check\" name=\"expand_bow_maxillary\" id=\"eb_maxillary_yes\" value=\"yes\" autocomplete=\"off\">\n                                <label class=\"btn btn-choice\" for=\"eb_maxillary_yes\">\u05d4\u05e8\u05d7\u05d1 \u05d0\u05ea \u05d4\u05e7\u05e9\u05ea<\/label>\n                            <\/div>\n                        <\/div>\n                        <div class=\"col-md-5 col-12 mt-2 mt-md-0\">\n                            <div class=\"input-group eb-mm-group d-none\" data-for=\"maxillary\" style=\"max-width: 200px;\">\n                                <input type=\"number\" min=\"0\" step=\"0.1\" class=\"form-control\" id=\"eb_maxillary_mm\" name=\"expand_bow_maxillary_mm\" placeholder=\"\">\n                                <span class=\"input-group-text\">\u05de\"\u05de<\/span>\n                            <\/div>\n                        <\/div>\n                    <\/div>\n                <\/div>\n            <\/div>\n\n            <div class=\"row align-items-center\">\n                <div class=\"col-lg-2 col-md-12\">\n                    <span class=\"small\">\u05dc\u05e1\u05ea \u05ea\u05d7\u05ea\u05d5\u05e0\u05d4<\/span>\n                <\/div>\n                <div class=\"col-lg-10 col-md-12\">\n                    <div class=\"row align-items-center\">\n                        <div class=\"col-md-7 col-12\">\n                            <div class=\"d-flex flex-wrap gap-2\">\n                                <input type=\"radio\" class=\"btn-check\" name=\"expand_bow_mandible\" id=\"eb_mandible_no\" value=\"no\" autocomplete=\"off\" checked>\n                                <label class=\"btn btn-choice\" for=\"eb_mandible_no\">\u05d0\u05dc \u05ea\u05e8\u05d7\u05d9\u05d1 \u05d0\u05ea \u05d4\u05e7\u05e9\u05ea<\/label>\n\n                                <input type=\"radio\" class=\"btn-check\" name=\"expand_bow_mandible\" id=\"eb_mandible_yes\" value=\"yes\" autocomplete=\"off\">\n                                <label class=\"btn btn-choice\" for=\"eb_mandible_yes\">\u05d4\u05e8\u05d7\u05d1 \u05d0\u05ea \u05d4\u05e7\u05e9\u05ea<\/label>\n                            <\/div>\n                        <\/div>\n                        <div class=\"col-md-5 col-12 mt-2 mt-md-0\">\n                            <div class=\"input-group eb-mm-group d-none\" data-for=\"mandible\" style=\"max-width: 200px;\">\n                                <input type=\"number\" min=\"0\" step=\"0.1\" class=\"form-control\" id=\"eb_mandible_mm\" name=\"expand_bow_mandible_mm\" placeholder=\"\">\n                                <span class=\"input-group-text\">\u05de\"\u05de<\/span>\n                            <\/div>\n                        <\/div>\n                    <\/div>\n                <\/div>\n            <\/div>\n        <\/div>\n        <!-- Expand the bow end here -->\n\n        <!--- Deglaze the adjacent side starts here --->\n        <div class=\"mt-4\">\n            <div class=\"form-label\">\u05d4\u05e1\u05e8 \u05d6\u05d9\u05d2\u05d5\u05d2 \u05de\u05d4\u05e6\u05d3 \u05d4\u05e1\u05de\u05d5\u05da <span class=\"text-danger\">\u05d9\u05d7\u05d9\u05d3\u05d4: \u05de\"\u05de<\/span><\/div>\n            <div class=\"\" role=\"group\" aria-label=\"\u05d4\u05e1\u05e8 \u05d6\u05d9\u05d2\u05d5\u05d2 \u05de\u05e6\u05d3 \u05e1\u05de\u05d5\u05da\">\n                <input type=\"radio\" class=\"btn-check\" name=\"deglaze_adjacent\" id=\"deglaze_3d\" value=\"3d_design_is_determined\" autocomplete=\"off\" checked>\n                <label class=\"btn btn btn-choice me-2\" for=\"deglaze_3d\">\u05e2\u05d9\u05e6\u05d5\u05d1 \u05ea\u05dc\u05ea \u05de\u05d9\u05de\u05d3 \u05e0\u05e7\u05d1\u05e2<\/label>\n\n                <input type=\"radio\" class=\"btn-check\" name=\"deglaze_adjacent\" id=\"deglaze_none\" value=\"do_not_deglaze\" autocomplete=\"off\">\n                <label class=\"btn btn btn-choice me-2\" for=\"deglaze_none\">\u05d0\u05dc \u05ea\u05e1\u05d9\u05e8 \u05d6\u05d9\u05d2\u05d5\u05d2<\/label>\n\n                <input type=\"radio\" class=\"btn-check\" name=\"deglaze_adjacent\" id=\"deglaze_specify\" value=\"specify_tooth_position\" autocomplete=\"off\">\n                <label class=\"btn btn btn-choice\" for=\"deglaze_specify\">\u05e6\u05d9\u05d9\u05df \u05d0\u05ea \u05de\u05d9\u05e7\u05d5\u05dd \u05d4\u05e9\u05df \u05dc\u05d4\u05e1\u05e8\u05ea \u05d6\u05d9\u05d2\u05d5\u05d2<\/label>\n            <\/div>\n            <div id=\"deglaze_positions_wrapper\" class=\"mt-3\" style=\"display:none;\">\n                <p class=\"small text-muted mb-2\">\u05d0\u05e0\u05d0 \u05ea\u05e2\u05d3 \u05d0\u05ea \u05d4\u05de\u05e9\u05d5\u05d1 \u05e2\u05dc \u05db\u05de\u05d5\u05ea \u05d4\u05e1\u05e8\u05ea \u05d4\u05d6\u05d9\u05d2\u05d5\u05d2<\/p>\n\n\t\t\t\t\n                <!-- Upper arch -->\n                <div class=\"row pb-3 border-1 border-bottom bottom-border-style-dashed mb-3\">\n                    <div class=\"col-md-6\">\n\t\t\t\t\t\t<div class=\"d-flex flex-wrap align-items-center flex-column justify-content-end border-end border-1 end-border-style-dashed\"><div class=\"d-flex flex-wrap mb-2\"><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">18<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">17<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">16<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">15<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">14<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">13<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">12<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">11<\/span><\/div><div class=\"d-flex flex-wrap\"><input type=\"text\" name=\"deglaze_amounts[18]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[17]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[16]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[15]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[14]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[13]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[12]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[11]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><\/div><\/div>                    <\/div>\n                    <div class=\"col-md-6\">\n\t\t\t\t\t\t<div class=\"d-flex flex-wrap align-items-center flex-column\"><div class=\"d-flex flex-wrap mb-2\"><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">21<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">22<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">23<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">24<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">25<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">26<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">27<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">28<\/span><\/div><div class=\"d-flex flex-wrap\"><input type=\"text\" name=\"deglaze_amounts[21]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[22]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[23]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[24]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[25]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[26]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[27]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[28]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><\/div><\/div>                    <\/div>\n                <\/div>\n\n                <!-- Lower arch -->\n                <div class=\"row\">\n                    <div class=\"col-md-6\">\n\t\t\t\t\t\t<div class=\"d-flex flex-wrap align-items-center flex-column justify-content-end border-end border-1 end-border-style-dashed\"><div class=\"d-flex flex-wrap mb-2\"><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">48<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">47<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">46<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">45<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">44<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">43<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">42<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">41<\/span><\/div><div class=\"d-flex flex-wrap\"><input type=\"text\" name=\"deglaze_amounts[48]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[47]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[46]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[45]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[44]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[43]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[42]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[41]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><\/div><\/div>                    <\/div>\n                    <div class=\"col-md-6\">\n\t\t\t\t\t\t<div class=\"d-flex flex-wrap align-items-center flex-column\"><div class=\"d-flex flex-wrap mb-2\"><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">31<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">32<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">33<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">34<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">35<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">36<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">37<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">38<\/span><\/div><div class=\"d-flex flex-wrap\"><input type=\"text\" name=\"deglaze_amounts[31]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[32]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[33]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[34]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[35]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[36]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[37]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"deglaze_amounts[38]\" class=\"form-control form-control-sm mx-2 deglaze-amount-input\" placeholder=\"\" style=\"width: 50px;\" \/><\/div><\/div>                    <\/div>\n                <\/div>\n            <\/div>\n        <\/div>\n        <!--- Deglaze the adjacent side ends here --->\n\n        <!--- Move away from the molars start here --->\n        <div class=\"mt-4\">\n            <div class=\"form-label fw-semibold mb-2\">\u05d4\u05ea\u05e8\u05d7\u05e7 \u05de\u05d4\u05d8\u05d5\u05d7\u05e0\u05d5\u05ea<\/div>\n\n            <div class=\"btn-group\">\n                <div class=\"mb-2\">\n                    <input type=\"checkbox\" class=\"btn-check\" name=\"move_away_molars[]\" id=\"mam_top_left\" value=\"top_left\" autocomplete=\"off\">\n                    <label class=\"btn btn btn-choice me-2\" for=\"mam_top_left\">\u05dc\u05de\u05e2\u05dc\u05d4 \u05e9\u05de\u05d0\u05dc<\/label>\n                <\/div>\n\n                <div class=\"mb-2\">\n                    <input type=\"checkbox\" class=\"btn-check\" name=\"move_away_molars[]\" id=\"mam_top_right\" value=\"top_right\" autocomplete=\"off\">\n                    <label class=\"btn btn btn-choice me-2\" for=\"mam_top_right\">\u05dc\u05de\u05e2\u05dc\u05d4 \u05d9\u05de\u05d9\u05df<\/label>\n                <\/div>\n\n                <div class=\"mb-2\">\n                    <input type=\"checkbox\" class=\"btn-check\" name=\"move_away_molars[]\" id=\"mam_bottom_left\" value=\"bottom_left\" autocomplete=\"off\">\n                    <label class=\"btn btn btn-choice me-2\" for=\"mam_bottom_left\">\u05dc\u05de\u05d8\u05d4 \u05e9\u05de\u05d0\u05dc<\/label>\n                <\/div>\n\n                <div class=\"mb-2\">\n                    <input type=\"checkbox\" class=\"btn-check\" name=\"move_away_molars[]\" id=\"mam_bottom_right\" value=\"bottom_right\" autocomplete=\"off\">\n                    <label class=\"btn btn btn-choice me-2\" for=\"mam_bottom_right\">\u05dc\u05de\u05d8\u05d4 \u05d9\u05de\u05d9\u05df<\/label>\n                <\/div>\n            <\/div>\n        <\/div>\n        <!--- Move away from the molars end here --->\n\n        <!--- Lips tilted start here --->\n        <div class=\"mt-4\">\n            <div class=\"form-label fw-semibold mb-2\">\u05e9\u05e4\u05ea\u05d9\u05d9\u05dd \u05de\u05d5\u05d8\u05d5\u05ea<\/div>\n\n            <!-- Maxillary row -->\n            <div class=\"row align-items-center mb-2\">\n                <div class=\"col-md-2 col-4\"><span class=\"small\">\u05dc\u05e1\u05ea \u05e2\u05dc\u05d9\u05d5\u05e0\u05d4<\/span><\/div>\n                <div class=\"col-md-10 col-8\">\n                    <input type=\"checkbox\" class=\"btn-check\" name=\"lips_tilted_maxillary\" id=\"lt_maxillary_allowed\" value=\"lip_tilt_is_allowed\" autocomplete=\"off\">\n                    <label class=\"btn btn btn-choice me-2\" for=\"lt_maxillary_allowed\">\u05d4\u05d8\u05d9\u05d9\u05ea \u05e9\u05e4\u05ea\u05d9\u05d9\u05dd \u05de\u05d5\u05ea\u05e8\u05ea<\/label>\n                <\/div>\n            <\/div>\n\n            <!-- Mandible row -->\n            <div class=\"row align-items-center\">\n                <div class=\"col-md-2 col-4\"><span class=\"small\">\u05dc\u05e1\u05ea \u05ea\u05d7\u05ea\u05d5\u05e0\u05d4<\/span><\/div>\n                <div class=\"col-md-10 col-8\">\n                    <input type=\"checkbox\" class=\"btn-check\" name=\"lips_tilted_mandible\" id=\"lt_mandible_allowed\" value=\"lip_tilt_is_allowed\" autocomplete=\"off\">\n                    <label class=\"btn btn btn-choice me-2\" for=\"lt_mandible_allowed\">\u05d4\u05d8\u05d9\u05d9\u05ea \u05e9\u05e4\u05ea\u05d9\u05d9\u05dd \u05de\u05d5\u05ea\u05e8\u05ea<\/label>\n                <\/div>\n            <\/div>\n        <\/div>\n        <!--- Lips tilted end here --->\n    <\/div>\n    <!--- Crowding is lifted (Tooth extraction) end here --->\n\n    <!--- Record gaps start here --->\n    <div class=\"mb-4 p-3 border rounded shadow-sm\">\n        <h5 class=\"mb-3\">\u05ea\u05e2\u05d3 \u05e8\u05d5\u05d5\u05d7\u05d9\u05dd<\/h5>\n        <p class=\"small text-muted\">\u05e8\u05d5\u05d5\u05d7 \u05e7\u05d3\u05de\u05d9 <span class=\"text-danger\">\u05d9\u05d7\u05d9\u05d3\u05d4: \u05de\"\u05de<\/span><\/p>\n        <p class=\"small text-muted\">\u05d0\u05e0\u05d0 \u05ea\u05e2\u05d3 \u05d0\u05ea \u05db\u05de\u05d5\u05ea \u05e8\u05d5\u05d5\u05d7 \u05d4\u05de\u05e9\u05d5\u05d1<\/p>\n\n\t\t\n        <!-- Upper arch -->\n        <div class=\"row pb-3 border-1 border-bottom bottom-border-style-dashed mb-3\">\n            <div class=\"col-md-6\">\n\t\t\t\t<div class=\"d-flex flex-wrap align-items-center flex-column justify-content-end border-end border-1 end-border-style-dashed\"><div class=\"d-flex flex-wrap mb-2\"><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">18<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">17<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">16<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">15<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">14<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">13<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">12<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">11<\/span><\/div><div class=\"d-flex flex-wrap\"><input type=\"text\" name=\"record_gaps[18]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[17]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[16]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[15]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[14]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[13]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[12]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[11]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><\/div><\/div>            <\/div>\n            <div class=\"col-md-6\">\n\t\t\t\t<div class=\"d-flex flex-wrap align-items-center flex-column\"><div class=\"d-flex flex-wrap mb-2\"><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">21<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">22<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">23<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">24<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">25<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">26<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">27<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">28<\/span><\/div><div class=\"d-flex flex-wrap\"><input type=\"text\" name=\"record_gaps[21]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[22]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[23]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[24]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[25]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[26]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[27]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[28]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><\/div><\/div>            <\/div>\n        <\/div>\n\n        <!-- Lower arch -->\n        <div class=\"row\">\n            <div class=\"col-md-6\">\n\t\t\t\t<div class=\"d-flex flex-wrap align-items-center flex-column justify-content-end border-end border-1 end-border-style-dashed\"><div class=\"d-flex flex-wrap mb-2\"><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">48<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">47<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">46<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">45<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">44<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">43<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">42<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">41<\/span><\/div><div class=\"d-flex flex-wrap\"><input type=\"text\" name=\"record_gaps[48]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[47]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[46]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[45]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[44]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[43]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[42]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[41]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><\/div><\/div>            <\/div>\n            <div class=\"col-md-6\">\n\t\t\t\t<div class=\"d-flex flex-wrap align-items-center flex-column\"><div class=\"d-flex flex-wrap mb-2\"><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">31<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">32<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">33<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">34<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">35<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">36<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">37<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">38<\/span><\/div><div class=\"d-flex flex-wrap\"><input type=\"text\" name=\"record_gaps[31]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[32]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[33]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[34]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[35]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[36]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[37]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"record_gaps[38]\" class=\"form-control form-control-sm mx-2 gap-record-input\" placeholder=\"\" style=\"width: 50px;\" \/><\/div><\/div>            <\/div>\n        <\/div>\n    <\/div>\n    <!--- Record gaps end here --->\n\n    <!--- Correction goals of the gap start here --->\n    <div class=\"mb-4 p-3 border rounded shadow-sm\">\n        <h5 class=\"mb-3\">\u05d9\u05e2\u05d3\u05d9 \u05ea\u05d9\u05e7\u05d5\u05df \u05d4\u05e8\u05d5\u05d5\u05d7<\/h5>\n        <p class=\"small text-muted\">\u05e1\u05d2\u05d5\u05e8 \u05d0\u05ea \u05d4\u05e8\u05d5\u05d5\u05d7<\/p>\n\n        <!-- Maxillary section -->\n        <div class=\"mb-3\">\n            <div class=\"row align-items-start mb-2\">\n                <div class=\"col-md-2\"><span class=\"fw-semibold\">\u05dc\u05e1\u05ea \u05e2\u05dc\u05d9\u05d5\u05e0\u05d4<\/span><\/div>\n                <div class=\"col-md-10\">\n                    <div class=\"d-flex flex-wrap gap-2\" role=\"group\" aria-label=\"\u05ea\u05d9\u05e7\u05d5\u05df \u05e8\u05d5\u05d5\u05d7 \u05dc\u05e1\u05ea \u05e2\u05dc\u05d9\u05d5\u05e0\u05d4\">\n                        <input type=\"radio\" class=\"btn-check\" name=\"gap_correction_maxillary\" id=\"gc_max_strong\" value=\"strong_resistance\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice\" for=\"gc_max_strong\">\u05d4\u05ea\u05e0\u05d2\u05d3\u05d5\u05ea \u05d7\u05d6\u05e7\u05d4<\/label>\n\n                        <input type=\"radio\" class=\"btn-check\" name=\"gap_correction_maxillary\" id=\"gc_max_middle\" value=\"the_middle_school_is_resisting\" autocomplete=\"off\" checked>\n                        <label class=\"btn btn-choice\" for=\"gc_max_middle\">\u05d1\u05d9\u05ea \u05d4\u05e1\u05e4\u05e8 \u05d4\u05ea\u05d9\u05db\u05d5\u05df \u05de\u05ea\u05e0\u05d2\u05d3<\/label>\n\n                        <input type=\"radio\" class=\"btn-check\" name=\"gap_correction_maxillary\" id=\"gc_max_weak\" value=\"weak_branch_resistance\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice\" for=\"gc_max_weak\">\u05d4\u05ea\u05e0\u05d2\u05d3\u05d5\u05ea \u05e2\u05e0\u05e4\u05d4 \u05d7\u05dc\u05e9\u05d4<\/label>\n\n                        <input type=\"radio\" class=\"btn-check\" name=\"gap_correction_maxillary\" id=\"gc_max_3d\" value=\"3d_design_is_determined\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice\" for=\"gc_max_3d\">\u05e2\u05d9\u05e6\u05d5\u05d1 \u05ea\u05dc\u05ea \u05de\u05d9\u05de\u05d3 \u05e0\u05e7\u05d1\u05e2<\/label>\n                    <\/div>\n                <\/div>\n            <\/div>\n        <\/div>\n\n        <!-- Mandible section -->\n        <div class=\"mb-3\">\n            <div class=\"row align-items-start mb-2\">\n                <div class=\"col-md-2\"><span class=\"fw-semibold\">\u05dc\u05e1\u05ea \u05ea\u05d7\u05ea\u05d5\u05e0\u05d4<\/span><\/div>\n                <div class=\"col-md-10\">\n                    <div class=\"d-flex flex-wrap gap-2\" role=\"group\" aria-label=\"\u05ea\u05d9\u05e7\u05d5\u05df \u05e8\u05d5\u05d5\u05d7 \u05dc\u05e1\u05ea \u05ea\u05d7\u05ea\u05d5\u05e0\u05d4\">\n                        <input type=\"radio\" class=\"btn-check\" name=\"gap_correction_mandible\" id=\"gc_man_strong\" value=\"strong_resistance\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice\" for=\"gc_man_strong\">\u05d4\u05ea\u05e0\u05d2\u05d3\u05d5\u05ea \u05d7\u05d6\u05e7\u05d4<\/label>\n\n                        <input type=\"radio\" class=\"btn-check\" name=\"gap_correction_mandible\" id=\"gc_man_middle\" value=\"the_middle_school_is_resisting\" autocomplete=\"off\" checked>\n                        <label class=\"btn btn-choice\" for=\"gc_man_middle\">\u05d1\u05d9\u05ea \u05d4\u05e1\u05e4\u05e8 \u05d4\u05ea\u05d9\u05db\u05d5\u05df \u05de\u05ea\u05e0\u05d2\u05d3<\/label>\n\n                        <input type=\"radio\" class=\"btn-check\" name=\"gap_correction_mandible\" id=\"gc_man_weak\" value=\"weak_branch_resistance\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice\" for=\"gc_man_weak\">\u05d4\u05ea\u05e0\u05d2\u05d3\u05d5\u05ea \u05e2\u05e0\u05e4\u05d4 \u05d7\u05dc\u05e9\u05d4<\/label>\n\n                        <input type=\"radio\" class=\"btn-check\" name=\"gap_correction_mandible\" id=\"gc_man_3d\" value=\"3d_design_is_determined\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice\" for=\"gc_man_3d\">\u05e2\u05d9\u05e6\u05d5\u05d1 \u05ea\u05dc\u05ea \u05de\u05d9\u05de\u05d3 \u05e0\u05e7\u05d1\u05e2<\/label>\n                    <\/div>\n                <\/div>\n            <\/div>\n        <\/div>\n\n        <!-- Reserve gaps section -->\n        <div class=\"mt-4\">\n            <div class=\"form-label fw-semibold mb-2\">\u05e9\u05de\u05d5\u05e8 \u05e8\u05d5\u05d5\u05d7\u05d9\u05dd <span class=\"text-danger\">\u05d9\u05d7\u05d9\u05d3\u05d4: \u05de\"\u05de<\/span><\/div>\n\n            <!-- Reserve gaps checkbox -->\n            <div class=\"mb-3\">\n                <input type=\"checkbox\" class=\"btn-check\" name=\"reserve_gaps_enable\" id=\"reserve_gaps_checkbox\" value=\"1\" autocomplete=\"off\">\n                <label class=\"btn btn btn-choice\" for=\"reserve_gaps_checkbox\">\u05e9\u05de\u05d5\u05e8 \u05e8\u05d5\u05d5\u05d7\u05d9\u05dd<\/label>\n            <\/div>\n\n            <div id=\"reserve_gaps_inputs_wrapper\" style=\"display:none;\">\n                <p class=\"small text-muted\">\u05d0\u05e0\u05d0 \u05ea\u05e2\u05d3 \u05d0\u05ea \u05db\u05de\u05d5\u05ea \u05e8\u05d5\u05d5\u05d7 \u05d4\u05de\u05e9\u05d5\u05d1<\/p>\n\n\t\t\t\t\n                <!-- Upper arch -->\n                <div class=\"row pb-3 border-1 border-bottom bottom-border-style-dashed mb-3\">\n                    <div class=\"col-md-6\">\n\t\t\t\t\t\t<div class=\"d-flex flex-wrap align-items-center flex-column justify-content-end border-end border-1 end-border-style-dashed\"><div class=\"d-flex flex-wrap mb-2\"><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">18<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">17<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">16<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">15<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">14<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">13<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">12<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">11<\/span><\/div><div class=\"d-flex flex-wrap\"><input type=\"text\" name=\"reserve_gaps[18]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[17]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[16]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[15]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[14]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[13]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[12]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[11]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><\/div><\/div>                    <\/div>\n                    <div class=\"col-md-6\">\n\t\t\t\t\t\t<div class=\"d-flex flex-wrap align-items-center flex-column\"><div class=\"d-flex flex-wrap mb-2\"><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">21<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">22<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">23<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">24<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">25<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">26<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">27<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">28<\/span><\/div><div class=\"d-flex flex-wrap\"><input type=\"text\" name=\"reserve_gaps[21]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[22]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[23]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[24]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[25]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[26]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[27]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[28]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><\/div><\/div>                    <\/div>\n                <\/div>\n\n                <!-- Lower arch -->\n                <div class=\"row\">\n                    <div class=\"col-md-6\">\n\t\t\t\t\t\t<div class=\"d-flex flex-wrap align-items-center flex-column justify-content-end border-end border-1 end-border-style-dashed\"><div class=\"d-flex flex-wrap mb-2\"><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">48<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">47<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">46<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">45<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">44<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">43<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">42<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">41<\/span><\/div><div class=\"d-flex flex-wrap\"><input type=\"text\" name=\"reserve_gaps[48]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[47]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[46]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[45]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[44]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[43]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[42]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[41]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><\/div><\/div>                    <\/div>\n                    <div class=\"col-md-6\">\n\t\t\t\t\t\t<div class=\"d-flex flex-wrap align-items-center flex-column\"><div class=\"d-flex flex-wrap mb-2\"><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">31<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">32<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">33<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">34<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">35<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">36<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">37<\/span><span class=\"btn btn-choice rounded-circle mx-2 d-flex align-items-center justify-content-center circle-btn is-static-label\">38<\/span><\/div><div class=\"d-flex flex-wrap\"><input type=\"text\" name=\"reserve_gaps[31]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[32]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[33]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[34]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[35]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[36]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[37]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><input type=\"text\" name=\"reserve_gaps[38]\" class=\"form-control form-control-sm mx-2 reserve-gap-input\" placeholder=\"\" style=\"width: 50px;\" \/><\/div><\/div>                    <\/div>\n                <\/div>\n            <\/div>\n        <\/div>\n    <\/div>\n    <!--- Correction goals of the gap end here --->\n\n    <!--- Occlusal relationship at the target position start here --->\n    <div class=\"mb-4 p-3 border rounded shadow-sm\">\n        <h5 class=\"mb-3\">\u05d9\u05d7\u05e1 \u05e1\u05d2\u05e8 \u05d1\u05de\u05d9\u05e7\u05d5\u05dd \u05d4\u05d9\u05e2\u05d3<\/h5>\n        <p class=\"small text-muted\">\u05db\u05d1\u05e8\u05d9\u05e8\u05ea \u05de\u05d7\u05d3\u05dc, \u05d9\u05d7\u05e1 \u05d4\u05e1\u05d2\u05e8 \u05d4\u05e8\u05d2\u05d9\u05dc \u05d9\u05e9\u05d5\u05d7\u05d6\u05e8 \u05db\u05db\u05dc \u05d4\u05d0\u05e4\u05e9\u05e8, \u05d5\u05d0\u05dd \u05d9\u05e9 \u05de\u05e7\u05e8\u05d9\u05dd \u05de\u05d9\u05d5\u05d7\u05d3\u05d9\u05dd, \u05d6\u05d4 \u05d9\u05d5\u05e1\u05d1\u05e8 \u05d1\u05ea\u05d5\u05db\u05e0\u05d9\u05ea \u05d4\u05ea\u05dc\u05ea \u05de\u05d9\u05de\u05d3<\/p>\n\n        <!-- Left section -->\n        <div class=\"mb-3\">\n            <div class=\"fw-semibold mb-2\">\u05e9\u05de\u05d0\u05dc<\/div>\n\n            <!-- Fangs row -->\n            <div class=\"row align-items-center mb-2\">\n                <div class=\"col-md-2\"><span class=\"small\">\u05e0\u05d9\u05d1\u05d9\u05dd<\/span><\/div>\n                <div class=\"col-md-10\">\n                    <div class=\"d-flex flex-wrap gap-2\" role=\"group\" aria-label=\"\u05e1\u05d9\u05d5\u05d5\u05d2 \u05e0\u05d9\u05d1\u05d9\u05dd \u05e9\u05de\u05d0\u05dc\u05d9\u05d9\u05dd\">\n                        <input type=\"radio\" class=\"btn-check\" name=\"occlusal_left_fangs\" id=\"olf_class1\" value=\"class_i\" autocomplete=\"off\" checked>\n                        <label class=\"btn btn-choice\" for=\"olf_class1\">\u05db\u05d9\u05ea\u05d4 I<\/label>\n\n                        <input type=\"radio\" class=\"btn-check\" name=\"occlusal_left_fangs\" id=\"olf_class2\" value=\"class_ii\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice\" for=\"olf_class2\">\u05db\u05d9\u05ea\u05d4 II<\/label>\n\n                        <input type=\"radio\" class=\"btn-check\" name=\"occlusal_left_fangs\" id=\"olf_class3\" value=\"class_iii\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice\" for=\"olf_class3\">\u05db\u05d9\u05ea\u05d4 III<\/label>\n\n                        <input type=\"radio\" class=\"btn-check\" name=\"occlusal_left_fangs\" id=\"olf_3d\" value=\"3d_design_is_determined\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice\" for=\"olf_3d\">\u05e2\u05d9\u05e6\u05d5\u05d1 \u05ea\u05dc\u05ea \u05de\u05d9\u05de\u05d3 \u05e0\u05e7\u05d1\u05e2<\/label>\n                    <\/div>\n                <\/div>\n            <\/div>\n\n            <!-- Teeth grinding relationship row -->\n            <div class=\"row align-items-center mb-2\">\n                <div class=\"col-md-2\"><span class=\"small\">\u05d9\u05d7\u05e1 \u05e9\u05d7\u05d9\u05e7\u05ea \u05e9\u05d9\u05e0\u05d9\u05d9\u05dd<\/span><\/div>\n                <div class=\"col-md-10\">\n                    <div class=\"d-flex flex-wrap gap-2\" role=\"group\" aria-label=\"\u05e1\u05d9\u05d5\u05d5\u05d2 \u05e9\u05d7\u05d9\u05e7\u05ea \u05e9\u05d9\u05e0\u05d9\u05d9\u05dd \u05e9\u05de\u05d0\u05dc\u05d9\">\n                        <input type=\"radio\" class=\"btn-check\" name=\"occlusal_left_grinding\" id=\"olg_class1\" value=\"class_i\" autocomplete=\"off\" checked>\n                        <label class=\"btn btn-choice\" for=\"olg_class1\">\u05db\u05d9\u05ea\u05d4 I<\/label>\n\n                        <input type=\"radio\" class=\"btn-check\" name=\"occlusal_left_grinding\" id=\"olg_class2\" value=\"class_ii\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice\" for=\"olg_class2\">\u05db\u05d9\u05ea\u05d4 II<\/label>\n\n                        <input type=\"radio\" class=\"btn-check\" name=\"occlusal_left_grinding\" id=\"olg_class3\" value=\"class_iii\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice\" for=\"olg_class3\">\u05db\u05d9\u05ea\u05d4 III<\/label>\n\n                        <input type=\"radio\" class=\"btn-check\" name=\"occlusal_left_grinding\" id=\"olg_3d\" value=\"3d_design_is_determined\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice\" for=\"olg_3d\">\u05e2\u05d9\u05e6\u05d5\u05d1 \u05ea\u05dc\u05ea \u05de\u05d9\u05de\u05d3 \u05e0\u05e7\u05d1\u05e2<\/label>\n                    <\/div>\n                <\/div>\n            <\/div>\n        <\/div>\n\n        <!-- Right section -->\n        <div class=\"mb-3\">\n            <div class=\"fw-semibold mb-2\">\u05d9\u05de\u05d9\u05df<\/div>\n\n            <!-- Fangs row -->\n            <div class=\"row align-items-center mb-2\">\n                <div class=\"col-md-2\"><span class=\"small\">\u05e0\u05d9\u05d1\u05d9\u05dd<\/span><\/div>\n                <div class=\"col-md-10\">\n                    <div class=\"d-flex flex-wrap gap-2\" role=\"group\" aria-label=\"\u05e1\u05d9\u05d5\u05d5\u05d2 \u05e0\u05d9\u05d1\u05d9\u05dd \u05d9\u05de\u05e0\u05d9\u05d9\u05dd\">\n                        <input type=\"radio\" class=\"btn-check\" name=\"occlusal_right_fangs\" id=\"orf_class1\" value=\"class_i\" autocomplete=\"off\" checked>\n                        <label class=\"btn btn-choice\" for=\"orf_class1\">\u05db\u05d9\u05ea\u05d4 I<\/label>\n\n                        <input type=\"radio\" class=\"btn-check\" name=\"occlusal_right_fangs\" id=\"orf_class2\" value=\"class_ii\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice\" for=\"orf_class2\">\u05db\u05d9\u05ea\u05d4 II<\/label>\n\n                        <input type=\"radio\" class=\"btn-check\" name=\"occlusal_right_fangs\" id=\"orf_class3\" value=\"class_iii\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice\" for=\"orf_class3\">\u05db\u05d9\u05ea\u05d4 III<\/label>\n\n                        <input type=\"radio\" class=\"btn-check\" name=\"occlusal_right_fangs\" id=\"orf_3d\" value=\"3d_design_is_determined\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice\" for=\"orf_3d\">\u05e2\u05d9\u05e6\u05d5\u05d1 \u05ea\u05dc\u05ea \u05de\u05d9\u05de\u05d3 \u05e0\u05e7\u05d1\u05e2<\/label>\n                    <\/div>\n                <\/div>\n            <\/div>\n\n            <!-- Teeth grinding relationship row -->\n            <div class=\"row align-items-center mb-2\">\n                <div class=\"col-md-2\"><span class=\"small\">\u05d9\u05d7\u05e1 \u05e9\u05d7\u05d9\u05e7\u05ea \u05e9\u05d9\u05e0\u05d9\u05d9\u05dd<\/span><\/div>\n                <div class=\"col-md-10\">\n                    <div class=\"d-flex flex-wrap gap-2\" role=\"group\" aria-label=\"\u05e1\u05d9\u05d5\u05d5\u05d2 \u05e9\u05d7\u05d9\u05e7\u05ea \u05e9\u05d9\u05e0\u05d9\u05d9\u05dd \u05d9\u05de\u05e0\u05d9\">\n                        <input type=\"radio\" class=\"btn-check\" name=\"occlusal_right_grinding\" id=\"org_class1\" value=\"class_i\" autocomplete=\"off\" checked>\n                        <label class=\"btn btn-choice\" for=\"org_class1\">\u05db\u05d9\u05ea\u05d4 I<\/label>\n\n                        <input type=\"radio\" class=\"btn-check\" name=\"occlusal_right_grinding\" id=\"org_class2\" value=\"class_ii\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice\" for=\"org_class2\">\u05db\u05d9\u05ea\u05d4 II<\/label>\n\n                        <input type=\"radio\" class=\"btn-check\" name=\"occlusal_right_grinding\" id=\"org_class3\" value=\"class_iii\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice\" for=\"org_class3\">\u05db\u05d9\u05ea\u05d4 III<\/label>\n\n                        <input type=\"radio\" class=\"btn-check\" name=\"occlusal_right_grinding\" id=\"org_3d\" value=\"3d_design_is_determined\" autocomplete=\"off\">\n                        <label class=\"btn btn-choice\" for=\"org_3d\">\u05e2\u05d9\u05e6\u05d5\u05d1 \u05ea\u05dc\u05ea \u05de\u05d9\u05de\u05d3 \u05e0\u05e7\u05d1\u05e2<\/label>\n                    <\/div>\n                <\/div>\n            <\/div>\n        <\/div>\n    <\/div>\n    <!--- Occlusal relationship at the target position end here --->\n\n    <!--- Cover covering start here --->\n    <div class=\"mb-4 p-3 border rounded shadow-sm\">\n        <h5 class=\"mb-3\">\u05db\u05d9\u05e1\u05d5\u05d9 \u05db\u05d9\u05e1\u05d5\u05d9<\/h5>\n        <p class=\"small text-muted\">\u05db\u05d1\u05e8\u05d9\u05e8\u05ea \u05de\u05d7\u05d3\u05dc, \u05db\u05d9\u05e1\u05d5\u05d9 \u05d4\u05db\u05d9\u05e1\u05d5\u05d9 \u05d4\u05e8\u05d2\u05d9\u05dc \u05d9\u05e9\u05d5\u05d7\u05d6\u05e8 \u05db\u05db\u05dc \u05d4\u05d0\u05e4\u05e9\u05e8, \u05d5\u05d0\u05dd \u05d9\u05e9 \u05de\u05e7\u05e8\u05d9\u05dd \u05de\u05d9\u05d5\u05d7\u05d3\u05d9\u05dd, \u05d6\u05d4 \u05d9\u05d5\u05e1\u05d1\u05e8 \u05d1\u05ea\u05d5\u05db\u05e0\u05d9\u05ea \u05d4\u05ea\u05dc\u05ea \u05de\u05d9\u05de\u05d3<\/p>\n\n        <div class=\"row align-items-center mb-2\">\n            <div class=\"col-md-1\"><span class=\"small\">\u05db\u05d9\u05e1\u05d5\u05d9<\/span><\/div>\n            <div class=\"col-md-11\">\n                <div class=\"d-flex flex-wrap gap-2 align-items-center\" role=\"group\" aria-label=\"\u05d0\u05e4\u05e9\u05e8\u05d5\u05d9\u05d5\u05ea \u05db\u05d9\u05e1\u05d5\u05d9\">\n                    <input type=\"radio\" class=\"btn-check\" name=\"cover_covering\" id=\"cc_normal\" value=\"normal_2_3mm\" autocomplete=\"off\" checked>\n                    <label class=\"btn btn-choice\" for=\"cc_normal\">\u05e8\u05d2\u05d9\u05dc (+2~3 \u05de\"\u05de)<\/label>\n                    <input type=\"radio\" class=\"btn-check\" name=\"cover_covering\" id=\"cc_sustain\" value=\"sustain\" autocomplete=\"off\">\n                    <label class=\"btn btn-choice\" for=\"cc_sustain\">\u05e7\u05d9\u05d9\u05dd<\/label>\n                    <input type=\"radio\" class=\"btn-check\" name=\"cover_covering\" id=\"cc_3d\" value=\"3d_design_is_determined\" autocomplete=\"off\">\n                    <label class=\"btn btn-choice\" for=\"cc_3d\">\u05e2\u05d9\u05e6\u05d5\u05d1 \u05ea\u05dc\u05ea \u05de\u05d9\u05de\u05d3 \u05e0\u05e7\u05d1\u05e2<\/label>\n                    <input type=\"radio\" class=\"btn-check\" name=\"cover_covering\" id=\"cc_other\" value=\"other\" autocomplete=\"off\">\n                    <label class=\"btn btn-choice\" for=\"cc_other\">\u05d0\u05d7\u05e8<\/label>\n                    \n                    <div class=\"input-group d-none mt-2\" id=\"cc_other_input_wrapper\" style=\"max-width: 200px;\">\n                        <input type=\"number\" min=\"0\" step=\"0.1\" class=\"form-control\" name=\"cover_covering_other\" placeholder=\"\">\n                        <span class=\"input-group-text\">\u05de\"\u05de<\/span>\n                    <\/div>\n                <\/div>\n            <\/div>\n        <\/div>\n\n        <div class=\"row align-items-center\">\n            <div class=\"col-md-1\"><span class=\"small\">\u05db\u05d9\u05e1\u05d5\u05d9<\/span><\/div>\n            <div class=\"col-md-11\">\n                <div class=\"d-flex flex-wrap gap-2 align-items-center\" role=\"group\" aria-label=\"\u05d0\u05e4\u05e9\u05e8\u05d5\u05d9\u05d5\u05ea \u05db\u05d9\u05e1\u05d5\u05d9 \u05ea\u05d7\u05ea\u05d5\u05df\">\n                    <input type=\"radio\" class=\"btn-check\" name=\"cover_lower\" id=\"cl_normal\" value=\"normal_2_3mm\" autocomplete=\"off\" checked>\n                    <label class=\"btn btn-choice\" for=\"cl_normal\">\u05e8\u05d2\u05d9\u05dc (+2~3 \u05de\"\u05de)<\/label>\n                    <input type=\"radio\" class=\"btn-check\" name=\"cover_lower\" id=\"cl_sustain\" value=\"sustain\" autocomplete=\"off\">\n                    <label class=\"btn btn-choice\" for=\"cl_sustain\">\u05e7\u05d9\u05d9\u05dd<\/label>\n                    <input type=\"radio\" class=\"btn-check\" name=\"cover_lower\" id=\"cl_3d\" value=\"3d_design_is_determined\" autocomplete=\"off\">\n                    <label class=\"btn btn-choice\" for=\"cl_3d\">\u05e2\u05d9\u05e6\u05d5\u05d1 \u05ea\u05dc\u05ea \u05de\u05d9\u05de\u05d3 \u05e0\u05e7\u05d1\u05e2<\/label>\n                    <input type=\"radio\" class=\"btn-check\" name=\"cover_lower\" id=\"cl_other\" value=\"other\" autocomplete=\"off\">\n                    <label class=\"btn btn-choice\" for=\"cl_other\">\u05d0\u05d7\u05e8<\/label>\n                    \n                    <div class=\"input-group d-none mt-2\" id=\"cl_other_input_wrapper\" style=\"max-width: 200px;\">\n                        <input type=\"number\" min=\"0\" step=\"0.1\" class=\"form-control\" name=\"cover_lower_other\" placeholder=\"\">\n                        <span class=\"input-group-text\">\u05de\"\u05de<\/span>\n                    <\/div>\n                <\/div>\n            <\/div>\n        <\/div>\n    <\/div>\n    <!--- Cover covering end here --->\n\n    <!--- Whether to use planting support nails start here --->\n    <div class=\"mb-4 p-3 border rounded shadow-sm\">\n        <h5 class=\"mb-3\">\u05d4\u05d0\u05dd \u05dc\u05d4\u05e9\u05ea\u05de\u05e9 \u05d1\u05de\u05e1\u05de\u05e8\u05d9 \u05ea\u05de\u05d9\u05db\u05d4 \u05dc\u05d4\u05e9\u05ea\u05dc\u05d4<\/h5>\n\n        <div class=\"d-flex flex-wrap gap-2\" role=\"group\" aria-label=\"\u05de\u05e1\u05de\u05e8\u05d9 \u05ea\u05de\u05d9\u05db\u05d4 \u05dc\u05d4\u05e9\u05ea\u05dc\u05d4\">\n            <input type=\"radio\" class=\"btn-check\" name=\"planting_support_nails\" id=\"psn_not\" value=\"not\" autocomplete=\"off\" checked>\n            <label class=\"btn btn-choice\" for=\"psn_not\">\u05dc\u05d0<\/label>\n\n            <input type=\"radio\" class=\"btn-check\" name=\"planting_support_nails\" id=\"psn_be\" value=\"be\" autocomplete=\"off\">\n            <label class=\"btn btn-choice\" for=\"psn_be\">\u05db\u05df<\/label>\n        <\/div>\n    <\/div>\n    <!--- Whether to use planting support nails end here --->\n\n    <!--- Whether to use the root bone system start here --->\n    <div class=\"mb-4 p-3 border rounded shadow-sm\">\n        <h5 class=\"mb-3\">\u05d4\u05d0\u05dd \u05dc\u05d4\u05e9\u05ea\u05de\u05e9 \u05d1\u05de\u05e2\u05e8\u05db\u05ea \u05e2\u05e6\u05dd \u05e9\u05d5\u05e8\u05e9<\/h5>\n        <p class=\"small text-muted\">\u05db\u05d3\u05d9 \u05dc\u05d4\u05e9\u05ea\u05de\u05e9 \u05d1\u05de\u05e2\u05e8\u05db\u05ea \u05d4\u05e9\u05d5\u05e8\u05e9, \u05e2\u05dc\u05d9\u05da \u05dc\u05d4\u05e2\u05dc\u05d5\u05ea \u05e0\u05ea\u05d5\u05e0\u05d9 CBCT \u05d1\u05e2\u05de\u05d5\u05d3 \u05de\u05d5\u05d3\u05dc \u05d4\u05e0\u05ea\u05d5\u05e0\u05d9\u05dd<\/p>\n\n        <div class=\"d-flex flex-wrap gap-2\" role=\"group\" aria-label=\"\u05de\u05e2\u05e8\u05db\u05ea \u05e2\u05e6\u05dd \u05e9\u05d5\u05e8\u05e9\">\n            <input type=\"radio\" class=\"btn-check\" name=\"root_bone_system\" id=\"rbs_not\" value=\"not\" autocomplete=\"off\" checked>\n            <label class=\"btn btn-choice\" for=\"rbs_not\">\u05dc\u05d0<\/label>\n\n            <input type=\"radio\" class=\"btn-check\" name=\"root_bone_system\" id=\"rbs_be\" value=\"be\" autocomplete=\"off\">\n            <label class=\"btn btn-choice\" for=\"rbs_be\">\u05db\u05df<\/label>\n        <\/div>\n    <\/div>\n    <!--- Whether to use the root bone system end here --->\n\n    <!--- The doctor added start here --->\n    <div class=\"mb-4 p-3 border rounded shadow-sm\">\n        <h5 class=\"mb-3\">\u05d4\u05e2\u05e8\u05ea \u05e8\u05d5\u05e4\u05d0<\/h5>\n        <p class=\"small text-muted\">\u05d0\u05e0\u05d0 \u05de\u05dc\u05d0 \u05db\u05d0\u05df \u05d3\u05e8\u05d9\u05e9\u05d5\u05ea \u05e0\u05d5\u05e1\u05e4\u05d5\u05ea \u05d4\u05e7\u05e9\u05d5\u05e8\u05d5\u05ea \u05dc\u05de\u05d9\u05e7\u05d5\u05dd \u05d4\u05d9\u05e2\u05d3.<\/p>\n\n        <div class=\"mb-3\">\n            <textarea class=\"form-control\" name=\"doctor_added_notes\" id=\"doctor_added_notes\" rows=\"6\" placeholder=\"\u05d4\u05d6\u05df \u05d3\u05e8\u05d9\u05e9\u05d5\u05ea \u05e0\u05d5\u05e1\u05e4\u05d5\u05ea...\"><\/textarea>\n        <\/div>\n    <\/div>\n    <!--- The doctor added end here --->\n\n    <script>\n        jQuery(document).ready(function($) {\n            \/\/ Store all tooth numbers for easy reference\n            var allTeethNumbers = ['17','16','15','14','13','12','11','21','22','23','24','25','26','27','47','46','45','44','43','42','41','31','32','33','34','35','36','37'];\n\n            \/\/ Function to update tooth availability based on selected teeth\n            function updateTeethAvailability() {\n                var ndmSelectedTeeth = [];\n                var teSelectedTeeth  = [];\n\n                \/\/ Collect selections\n                $('.ndm-tooth-checkbox:checked').each(function(){ ndmSelectedTeeth.push($(this).val()); });\n                $('.te-tooth-checkbox:checked').each(function(){ teSelectedTeeth.push($(this).val()); });\n\n                \/\/ 1) Full reset for NDM\/TE widgets (inputs + lock icons)\n                allTeethNumbers.forEach(function(toothNum) {\n                    \/\/ NDM\n                    $('#ndm_teeth_' + toothNum).prop('disabled', false).removeClass('disabled-tooth');\n                    $('label[for=\"ndm_teeth_' + toothNum + '\"]').removeClass('disabled');\n                    $('#ndm_teeth_' + toothNum).closest('.tooth-lock-container')\n                        .removeClass('tooth-button-locked tooth-button-disabled');\n\n                    \/\/ TE\n                    $('#te_ext_' + toothNum).prop('disabled', false).removeClass('disabled-tooth');\n                    $('label[for=\"te_ext_' + toothNum + '\"]').removeClass('disabled');\n                    $('#te_ext_' + toothNum).closest('.tooth-lock-container')\n                        .removeClass('tooth-button-locked tooth-button-disabled');\n                });\n\n                \/\/ 2) Re-enable auxiliary text inputs and clear disabled style on number circles\n                allTeethNumbers.forEach(function(toothNum){\n                    $('input[name=\"record_gaps['  + toothNum + ']\"]').prop('disabled', false).removeClass('disabled-input');\n                    $('input[name=\"reserve_gaps[' + toothNum + ']\"]').prop('disabled', false).removeClass('disabled-input');\n                    $('input[name=\"deglaze_amounts[' + toothNum + ']\"]').prop('disabled', false).removeClass('disabled-input');\n\n                    \/\/ remove disabled look from any matching number circle (gap\/deglaze sections)\n                    $('.circle-btn').filter(function(){ return $(this).text().trim() === toothNum; })\n                        .removeClass('circle-disabled');\n                });\n\n                \/\/ 3) Mirror NDM locks into TE (keep TE enabled)\n                ndmSelectedTeeth.forEach(function(toothNum) {\n                    \/\/ NDM gets yellow lock\n                    $('#ndm_teeth_' + toothNum).closest('.tooth-lock-container').addClass('tooth-button-locked');\n\n                    \/\/ TE shows same lock but stays enabled\n                    $('#te_ext_' + toothNum)\n                        .prop('disabled', false)\n                        .removeClass('disabled-tooth');\n                    $('label[for=\"te_ext_' + toothNum + '\"]').removeClass('disabled');\n                    $('#te_ext_' + toothNum).closest('.tooth-lock-container')\n                        .removeClass('tooth-button-disabled')\n                        .addClass('tooth-button-locked');\n                });\n\n                \/\/ 4) TE selection disables the same tooth in NDM and text inputs + dims number circles\n                teSelectedTeeth.forEach(function(toothNum) {\n                    \/\/ disable in NDM\n                    $('#ndm_teeth_' + toothNum).prop('disabled', true).addClass('disabled-tooth');\n                    $('label[for=\"ndm_teeth_' + toothNum + '\"]').addClass('disabled');\n                    $('#ndm_teeth_' + toothNum).closest('.tooth-lock-container').addClass('tooth-button-disabled');\n\n                    \/\/ disable auxiliary text inputs\n                    $('input[name=\"record_gaps['  + toothNum + ']\"]').prop('disabled', true).addClass('disabled-input');\n                    $('input[name=\"reserve_gaps[' + toothNum + ']\"]').prop('disabled', true).addClass('disabled-input');\n                    $('input[name=\"deglaze_amounts[' + toothNum + ']\"]').prop('disabled', true).addClass('disabled-input');\n\n                    \/\/ visually dim the corresponding number circles\n                    \/*$('.circle-btn').filter(function(){ return $(this).text().trim() === toothNum; })\n                        .addClass('circle-disabled');*\/\n                });\n            }\n\n            \/\/ Toggle \"Not designed to move teeth\" grid\n            $('input[name=\"ndm_option\"]').on('change', function() {\n                if ($('#ndm_following_teeth').is(':checked')) {\n                    $('#ndm_teeth_wrapper').slideDown(200);\n                } else {\n                    $('#ndm_teeth_wrapper').slideUp(200);\n                    $('input[name=\"ndm_teeth[]\"]').prop('checked', false);\n                    updateTeethAvailability();\n                }\n            });\n\n            \/\/ Toggle \"Tooth Extraction\" teeth grid\n            $('input[name=\"te_extraction_option\"]').on('change', function() {\n                if ($('#te_following_extraction').is(':checked')) {\n                    $('#te_extraction_wrapper').slideDown(200);\n                } else {\n                    $('#te_extraction_wrapper').slideUp(200);\n                    $('input[name=\"te_extraction_teeth[]\"]').prop('checked', false);\n                    updateTeethAvailability();\n                }\n            });\n\n            \/\/ Handle NDM tooth selection changes\n            $(document).on('change', '.ndm-tooth-checkbox', function() {\n                updateTeethAvailability();\n            });\n\n            \/\/ Handle TE tooth selection changes\n            $(document).on('change', '.te-tooth-checkbox', function() {\n                updateTeethAvailability();\n            });\n\n            \/\/ Expand the bow: show\/hide mm inputs per jaw\n            function toggleExpandBow(group) {\n                var isYes = $('#eb_' + group + '_yes').is(':checked');\n                var $wrap = $('.eb-mm-group[data-for=\"' + group + '\"]');\n                if (isYes) {\n                    $wrap.removeClass('d-none');\n                } else {\n                    $wrap.addClass('d-none');\n                    $wrap.find('input').val('');\n                }\n            }\n\n            $('input[name=\"expand_bow_maxillary\"]').on('change', function () {\n                toggleExpandBow('maxillary');\n            });\n            $('input[name=\"expand_bow_mandible\"]').on('change', function () {\n                toggleExpandBow('mandible');\n            });\n\n            \/\/ Toggle deglaze positions wrapper\n            $('input[name=\"deglaze_adjacent\"]').on('change', function() {\n                if ($('#deglaze_specify').is(':checked')) {\n                    $('#deglaze_positions_wrapper').slideDown(200);\n                } else {\n                    $('#deglaze_positions_wrapper').slideUp(200);\n                    $('.deglaze-amount-input').val('');\n                }\n            });\n\n            \/\/ Simple alternative for reserve gaps\n            $(document).on('click', 'label[for=\"reserve_gaps_checkbox\"]', function() {\n                setTimeout(function() {\n                    var isChecked = $('#reserve_gaps_checkbox').is(':checked');\n                    if (isChecked) {\n                        $('#reserve_gaps_inputs_wrapper').show();\n                    } else {\n                        $('#reserve_gaps_inputs_wrapper').hide();\n                    }\n                }, 100);\n            });\n\n            \/\/ Initialize on page load\n            toggleExpandBow('maxillary');\n            toggleExpandBow('mandible');\n\n            \/\/ Ensure correct initial visibility on load\n            $('input[name=\"te_extraction_option\"]:checked').trigger('change');\n            $('input[name=\"ndm_option\"]:checked').trigger('change');\n            $('input[name=\"deglaze_adjacent\"]:checked').trigger('change');\n        });\n    <\/script>\n\t                        <div class=\"d-flex justify-content-between\">\n                            <button type=\"button\" class=\"btn btn-secondary text-white cs-previous-step\" data-step=\"4\">\u05e7\u05d5\u05d3\u05dd<\/button>\n                            <button type=\"button\" class=\"btn btn-primary cs-next-step btn-lg\" data-current-step=\"5\">\u05e9\u05dc\u05d1 \u05d4\u05d1\u05d0<\/button>\n                        <\/div>\n                    <\/div>\n\n                    <div class=\"cs-step-pane d-none\" data-step=\"6\">\n                        \t<h2>\u05d0\u05d5\u05e8\u05ea\u05d5\u05d3\u05d5\u05e0\u05d8\u05d9\u05d4 \u05e7\u05d5\u05e0\u05d1\u05e0\u05e6\u05d9\u05d5\u05e0\u05dc\u05d9\u05ea - \u05dc\u05e1\u05ea \u05de\u05dc\u05d0\u05d4 (\u05de\u05d9\u05d9\u05e9\u05e8\u05d9\u05dd \u05d1\u05dc\u05ea\u05d9 \u05e0\u05e8\u05d0\u05d9\u05dd \u05dc\u05dc\u05d0 \u05e1\u05d5\u05d2\u05e8\u05d9\u05d9\u05dd)<\/h2>\n\n\t<!--- Product Type start here --->\n\t<div class=\"mb-4 p-3 border rounded shadow-sm\">\n\t\t<h5 class=\"mb-3\">\u05e1\u05d5\u05d2 \u05de\u05d5\u05e6\u05e8:<\/h5>\n\n\t\t<div class=\"btn-group\" role=\"group\" aria-label=\"\u05d1\u05d7\u05d9\u05e8\u05ea \u05e1\u05d5\u05d2 \u05de\u05d5\u05e6\u05e8\">\n\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"product_type\" id=\"pt_type_a\" value=\"type_a\" autocomplete=\"off\" checked>\n\t\t\t<label class=\"btn btn-choice rounded\" for=\"pt_type_a\">\u05e1\u05d5\u05d2 A<\/label>\n\t\t<\/div>\n\t<\/div>\n\t<!--- Product Type end here --->\n\n\t<!--- No attachment teeth are designed start here --->\n\t<div class=\"mb-4 p-3 border rounded shadow-sm\">\n\t\t<h5 class=\"mb-3\">\u05d0\u05d9\u05df \u05e9\u05d9\u05e0\u05d9\u05d9\u05dd \u05de\u05e2\u05d5\u05e6\u05d1\u05d5\u05ea \u05e2\u05dd \u05d7\u05d9\u05d1\u05d5\u05e8\u05d9\u05dd<\/h5>\n\n\t\t<div class=\"mb-3\">\n\t\t\t<div class=\"d-flex flex-wrap gap-2\" role=\"group\" aria-label=\"\u05d0\u05e4\u05e9\u05e8\u05d5\u05d9\u05d5\u05ea \u05e9\u05d9\u05e0\u05d9\u05d9\u05dd \u05e2\u05dd \u05d7\u05d9\u05d1\u05d5\u05e8\u05d9\u05dd\">\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"attachment_teeth_option\" id=\"at_not\" value=\"not\" autocomplete=\"off\" checked>\n\t\t\t\t<label class=\"btn btn-choice\" for=\"at_not\">\u05dc\u05d0<\/label>\n\n\t\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"attachment_teeth_option\" id=\"at_following_teeth\" value=\"the_following_teeth_are_not_designed_with_attachments\" autocomplete=\"off\">\n\t\t\t\t<label class=\"btn btn-choice\" for=\"at_following_teeth\">\u05d4\u05e9\u05d9\u05e0\u05d9\u05d9\u05dd \u05d4\u05d1\u05d0\u05d5\u05ea \u05d0\u05d9\u05e0\u05df \u05de\u05e2\u05d5\u05e6\u05d1\u05d5\u05ea \u05e2\u05dd \u05d7\u05d9\u05d1\u05d5\u05e8\u05d9\u05dd<\/label>\n\t\t\t<\/div>\n\t\t<\/div>\n\n\t\t<div id=\"attachment_teeth_wrapper\" style=\"display:none;\">\n\t\t\t<p class=\"small text-muted\">\u05d1\u05d7\u05e8 \u05d0\u05ea \u05d4\u05e9\u05d9\u05e0\u05d9\u05d9\u05dd \u05e9\u05dc\u05d0 \u05e6\u05e8\u05d9\u05db\u05d5\u05ea \u05dc\u05d4\u05d9\u05d5\u05ea \u05de\u05e2\u05d5\u05e6\u05d1\u05d5\u05ea \u05e2\u05dd \u05d7\u05d9\u05d1\u05d5\u05e8\u05d9\u05dd<\/p>\n\t\t\t<div class=\"row\">\n\t\t\t\t<div class=\"col-md-6 pb-2 justify-content-end d-flex flex-wrap border-end border-1 end-border-style-dashed\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_55\" value=\"55\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_55\">55<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_54\" value=\"54\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_54\">54<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_53\" value=\"53\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_53\">53<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_52\" value=\"52\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_52\">52<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_51\" value=\"51\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_51\">51<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-md-6 d-flex flex-wrap pb-2\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_61\" value=\"61\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_61\">61<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_62\" value=\"62\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_62\">62<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_63\" value=\"63\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_63\">63<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_64\" value=\"64\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_64\">64<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_65\" value=\"65\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_65\">65<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"row pt-2 pb-2 border-1 border-bottom bottom-border-style-dashed\">\n\t\t\t\t<div class=\"col-md-6 pt-2 pb-2 justify-content-end d-flex flex-wrap border-end border-1 end-border-style-dashed\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_48\" value=\"48\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_48\">48<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_47\" value=\"47\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_47\">47<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_46\" value=\"46\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_46\">46<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_45\" value=\"45\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_45\">45<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_44\" value=\"44\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_44\">44<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_43\" value=\"43\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_43\">43<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_42\" value=\"42\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_42\">42<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_41\" value=\"41\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_41\">41<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-md-6 pt-2 d-flex flex-wrap pb-2\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_31\" value=\"31\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_31\">31<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_32\" value=\"32\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_32\">32<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_33\" value=\"33\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_33\">33<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_34\" value=\"34\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_34\">34<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_35\" value=\"35\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_35\">35<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_36\" value=\"36\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_36\">36<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_37\" value=\"37\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_37\">37<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_38\" value=\"38\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_38\">38<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"row pt-2\">\n\t\t\t\t<div class=\"col-md-6 pb-2 justify-content-end d-flex flex-wrap border-end border-1 end-border-style-dashed\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_85\" value=\"85\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_85\">85<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_84\" value=\"84\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_84\">84<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_83\" value=\"83\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_83\">83<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_82\" value=\"82\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_82\">82<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_81\" value=\"81\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_81\">81<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-md-6 d-flex flex-wrap pb-2\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_71\" value=\"71\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_71\">71<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_72\" value=\"72\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_72\">72<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_73\" value=\"73\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_73\">73<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_74\" value=\"74\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_74\">74<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"tooth-lock-container\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" class=\"btn-check attachment-tooth-checkbox\" name=\"no_attachment_teeth[]\" id=\"at_teeth_75\" value=\"75\" autocomplete=\"off\">\n\t\t\t\t\t\t\t<label class=\"btn btn btn-choice rounded-circle mx-2 mb-1 d-flex align-items-center justify-content-center circle-btn\" for=\"at_teeth_75\">75<div class=\"tooth-lock-icon\"><\/div><\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<!--- No attachment teeth are designed end here --->\n\n\t<!--- Whether to treat remotely start here --->\n\t<div class=\"mb-4 p-3 border rounded shadow-sm\">\n\t\t<h5 class=\"mb-3\">\u05d4\u05d0\u05dd \u05dc\u05d8\u05e4\u05dc \u05de\u05e8\u05d7\u05d5\u05e7<\/h5>\n\n\t\t<div class=\"d-flex flex-wrap gap-2\" role=\"group\" aria-label=\"\u05d0\u05e4\u05e9\u05e8\u05d5\u05d9\u05d5\u05ea \u05d8\u05d9\u05e4\u05d5\u05dc \u05de\u05e8\u05d7\u05d5\u05e7\">\n\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"treat_remotely\" id=\"tr_not\" value=\"not\" autocomplete=\"off\" checked>\n\t\t\t<label class=\"btn btn-choice\" for=\"tr_not\">\u05dc\u05d0<\/label>\n\n\t\t\t<input type=\"radio\" class=\"btn-check\" name=\"treat_remotely\" id=\"tr_be\" value=\"be\" autocomplete=\"off\">\n\t\t\t<label class=\"btn btn-choice\" for=\"tr_be\">\u05db\u05df<\/label>\n\t\t<\/div>\n\t<\/div>\n\t<!--- Whether to treat remotely end here --->\n\n\t<!--- The doctor added start here --->\n\t<div class=\"mb-4 p-3 border rounded shadow-sm\">\n\t\t<h5 class=\"mb-3\">\u05d4\u05e2\u05e8\u05ea \u05e8\u05d5\u05e4\u05d0<\/h5>\n\t\t<p class=\"small text-muted\">\u05d0\u05dd \u05d9\u05e9 \u05dc\u05da \u05d3\u05e8\u05d9\u05e9\u05d5\u05ea \u05e2\u05d9\u05e6\u05d5\u05d1 \u05de\u05d9\u05d9\u05e9\u05e8 \u05e0\u05d5\u05e1\u05e4\u05d5\u05ea, \u05d0\u05e0\u05d0 \u05de\u05dc\u05d0 \u05d0\u05d5\u05ea\u05df \u05dc\u05de\u05d8\u05d4<\/p>\n\n\t\t<div class=\"mb-3\">\n\t\t\t<textarea class=\"form-control\" name=\"aligner_doctor_added_notes\" id=\"aligner_doctor_added_notes\" rows=\"6\" placeholder=\"\u05d4\u05d6\u05df \u05d3\u05e8\u05d9\u05e9\u05d5\u05ea \u05e2\u05d9\u05e6\u05d5\u05d1 \u05de\u05d9\u05d9\u05e9\u05e8 \u05e0\u05d5\u05e1\u05e4\u05d5\u05ea...\"><\/textarea>\n\t\t<\/div>\n\t<\/div>\n\t<!--- The doctor added end here --->\n\t                        <div class=\"d-flex justify-content-between\">\n                            <button type=\"button\" class=\"btn btn-secondary text-white cs-previous-step\" data-step=\"5\">\u05e7\u05d5\u05d3\u05dd<\/button>\n                            <button type=\"button\" class=\"btn btn-primary cs-next-step btn-lg\" data-current-step=\"6\">\u05e9\u05dc\u05d1 \u05d4\u05d1\u05d0<\/button>\n                        <\/div>\n                    <\/div>\n\n                    <div class=\"cs-step-pane d-none\" data-step=\"7\">\n                        <h2>\u05ea\u05e6\u05d5\u05d2\u05d4 \u05de\u05e7\u05d3\u05d9\u05de\u05d4 \u05d5\u05d4\u05d2\u05e9\u05d4<\/h2>\n                        <div id=\"case-preview-content\">\n                            <\/div>\n                        <div class=\"d-flex justify-content-between mt-4\">\n                            <button type=\"button\" class=\"btn btn-secondary text-white cs-previous-step\" data-step=\"6\">\u05e7\u05d5\u05d3\u05dd<\/button>\n                            <div>\n                                <button type=\"button\" class=\"btn btn-primary cs-next-step cs-submit-case btn-lg\" id=\"submit-case-btn\">\u05d4\u05d2\u05e9 \u05de\u05e7\u05e8\u05d4<\/button>\n                                <button type=\"button\" class=\"btn btn-primary cs-next-step cs-update-case btn-lg d-none\" id=\"update-case-btn\">\u05e2\u05d3\u05db\u05df \u05de\u05e7\u05e8\u05d4<\/button>\n                            <\/div>\n                        <\/div>\n                    <\/div>\n\n                <\/section>\n            <\/div><div id=\"submission-success\" class=\"d-none\">\n                <div class=\"submission-success-content\">\n                    <div class=\"success-icon\">\u2713<\/div>\n                    <h2>\u05d4\u05de\u05e7\u05e8\u05d4 \u05d4\u05d5\u05d2\u05e9 \u05d1\u05d4\u05e6\u05dc\u05d7\u05d4!<\/h2>\n                    <p class=\"text-muted\">\u05ea\u05d5\u05d3\u05d4 \u05e9\u05d4\u05d2\u05e9\u05ea \u05d0\u05ea \u05d4\u05de\u05e7\u05e8\u05d4 \u05d4\u05e7\u05dc\u05d9\u05e0\u05d9 \u05e9\u05dc\u05da.<\/p>\n                    <p class=\"case-id-display\">\u05de\u05e1\u05e4\u05e8 \u05d4\u05de\u05e7\u05e8\u05d4 \u05e9\u05dc\u05da \u05d4\u05d5\u05d0: <strong id=\"submitted-case-id\"><\/strong><\/p>\n                    <div class=\"success-actions\">\n                        <a href=\"https:\/\/orthodontist.clear-smile.co.il\/he\/case-dashboard\/\" class=\"btn btn-primary btn-lg\">\u05e2\u05d1\u05d5\u05e8 \u05dc\u05dc\u05d5\u05d7 \u05d1\u05e7\u05e8\u05d4<\/a>\n    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style=\"max-height: 90vh; width: auto; display: block; margin: 0 auto; border-radius: 5px;\"> \n                            \n                            <button type=\"button\" class=\"btn-close btn-close-white cs-lightbox-close-btn\" data-bs-dismiss=\"modal\" aria-label=\"\u05e1\u05d2\u05d5\u05e8\"><\/button> \n\n                        <\/div>\n                    <\/div>\n\n                <\/div>\n            <\/div>\n        <\/div>\n\n\n        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