{"id":4889,"date":"2025-04-08T11:42:09","date_gmt":"2025-04-08T03:42:09","guid":{"rendered":"https:\/\/uni-pharma.com.tw\/payment\/"},"modified":"2025-05-16T22:36:52","modified_gmt":"2025-05-16T14:36:52","slug":"online-payment","status":"publish","type":"page","link":"https:\/\/uni-pharma.com.tw\/en\/online-payment\/","title":{"rendered":"Online Payment"},"content":{"rendered":"\n<div class=\"wp-block-stackable-columns alignfull stk-block-columns stk-block stk-a0aabf2 payment_form_outer\" data-block-id=\"a0aabf2\"><style>.stk-a0aabf2 {max-width:90% !important;min-width:auto !important;padding-top:40px !important;padding-bottom:100px !important;margin-right:auto !important;margin-bottom:0px !important;margin-left:auto !important;}.stk-a0aabf2-column{--stk-columns-spacing:0px !important;--stk-column-gap:100px !important;}@media screen and (max-width:689px){.stk-a0aabf2 {padding-top:10px !important;padding-bottom:30px !important;}.stk-a0aabf2-column{row-gap:50px !important;}}<\/style><div class=\"stk-row stk-inner-blocks stk-block-content stk-content-align stk-a0aabf2-column\">\n<div class=\"wp-block-stackable-column stk-block-column stk-column stk-block stk-b557ef5\" data-v=\"4\" data-block-id=\"b557ef5\"><style>@media screen and (min-width:690px){.stk-b557ef5 {flex:var(--stk-flex-grow, 1) 1 calc(42.4% - var(--stk-column-gap, 0px) * 1 \/ 2 ) !important;}}<\/style><div class=\"stk-column-wrapper stk-block-column__content stk-container stk-b557ef5-container stk--no-background stk--no-padding\"><div class=\"has-text-align-left stk-block-content stk-inner-blocks stk-b557ef5-inner-blocks\">\n<div class=\"wp-block-stackable-heading stk-block-heading stk-block-heading--v2 stk-block stk-d227258\" id=\"medical-testing-online-payment-form\" data-block-id=\"d227258\"><style>.stk-d227258 {margin-bottom:30px !important;}@media screen and (max-width:689px){.stk-d227258 {margin-bottom:20px !important;}.stk-d227258 .stk-block-heading__text{line-height:46px !important;}}<\/style><h1 class=\"stk-block-heading__text\">Medical Testing\u2028Online Payment Form<\/h1><\/div>\n\n\n\n<div class=\"wp-block-stackable-divider stk-block-divider has-text-align-left stk-block stk-903fc65\" data-block-id=\"903fc65\"><style>.stk-903fc65 hr.stk-block-divider__hr{background:var(--theme-palette-color-1, #ffcd05) !important;height:3px !important;width:100% !important;}.stk-903fc65 {margin-bottom:30px !important;}@media screen and (max-width:689px){.stk-903fc65 {margin-bottom:20px !important;}}<\/style><style class=\"stk-custom-css\">.stk-903fc65.stk-block-divider{max-width:60px !important}<\/style><hr class=\"stk-block-divider__hr\"\/><\/div>\n\n\n\n<div class=\"wp-block-stackable-text stk-block-text stk-block stk-3254484 link_text\" data-block-id=\"3254484\"><style>.stk-3254484 {margin-bottom:20px !important;}.stk-3254484 .stk-block-text__text{font-size:16px !important;line-height:26px !important;}@media screen and (max-width:999px){.stk-3254484 .stk-block-text__text{font-size:16px !important;}}<\/style><p class=\"stk-block-text__text\">Welcome to UniPharma\u2019s Medical Testing Online Payment System.\u2028Here, you can conveniently complete payments for your medical testing services. Upon successful payment, you will receive a confirmation via email and SMS containing the transaction details.<br>If you have any questions or concerns, please feel free to contact us using the information below. We are committed to providing you service.<br><br>*We won\u2019t ask you to operate an ATM or online banking service via phone. If you encounter any suspicious activity, please call our customer service immediately for verification.<br><br><strong>Service Hotline:<\/strong> <a href=\"tel:+886-2-2658-2577\">+886-2-2658-2577 #241<\/a> <br><strong>Service Hours: <\/strong>Monday to Friday, 9:30 AM \u2013 5:00 PM <br>You may also contact us via our official LINE service: <a href=\"https:\/\/lin.ee\/vqMQDXM\" target=\"_blank\" rel=\"noopener\">https:\/\/lin.ee\/vqMQDXM<\/a><\/p><\/div>\n\n\n\n<div class=\"wp-block-stackable-image stk-block-image stk-block stk-ac076a1\" data-block-id=\"ac076a1\"><style>.stk-ac076a1 {margin-bottom:40px !important;}.stk-ac076a1 .stk-img-wrapper{width:108px !important;height:108px !important;}@media screen and (max-width:689px){.stk-ac076a1 {margin-bottom:30px !important;}}<\/style><figure><span class=\"stk-img-wrapper stk-image--shape-stretch\"><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" class=\"stk-img wp-image-4519\" src=\"https:\/\/i0.wp.com\/uni-pharma.com.tw\/wp-content\/uploads\/2025\/04\/barcode.png?resize=112%2C112&#038;ssl=1\" width=\"112\" height=\"112\" srcset=\"https:\/\/i0.wp.com\/uni-pharma.com.tw\/wp-content\/uploads\/2025\/04\/barcode.png?w=112&amp;ssl=1 112w, https:\/\/i0.wp.com\/uni-pharma.com.tw\/wp-content\/uploads\/2025\/04\/barcode.png?resize=90%2C90&amp;ssl=1 90w\" sizes=\"auto, (max-width: 112px) 100vw, 112px\" \/><\/span><\/figure><\/div>\n\n\n\n<div class=\"wp-block-stackable-button-group stk-block-button-group stk-block stk-c93f4ce\" data-block-id=\"c93f4ce\"><div class=\"stk-row stk-inner-blocks stk-block-content stk-button-group\">\n<div class=\"wp-block-stackable-button stk-block-button stk-block stk-2aabd65\" data-block-id=\"2aabd65\"><style>.stk-2aabd65 .stk-button{padding-top:13.5px !important;padding-right:26px !important;padding-bottom:13.5px !important;padding-left:26px !important;}.stk-2aabd65 .stk-button__inner-text{font-size:16px !important;line-height:16px !important;}@media screen and (max-width:999px){.stk-2aabd65 .stk-button__inner-text{font-size:16px !important;}}<\/style><a class=\"stk-link stk-button stk--hover-effect-darken\" href=\"\/?page_id=4851\"><span class=\"stk-button__inner-text\">View Payment Records<\/span><\/a><\/div>\n<\/div><\/div>\n<\/div><\/div><\/div>\n\n\n\n<div class=\"wp-block-stackable-column stk-block-column stk-column stk-block stk-87536c1\" data-v=\"4\" data-block-id=\"87536c1\"><style>@media screen and (min-width:690px){.stk-87536c1 {flex:var(--stk-flex-grow, 1) 1 calc(57.6% - var(--stk-column-gap, 0px) * 1 \/ 2 ) !important;}}<\/style><div class=\"stk-column-wrapper stk-block-column__content stk-container stk-87536c1-container stk--no-background stk--no-padding\"><div class=\"stk-block-content stk-inner-blocks stk-87536c1-inner-blocks\"><script>\nvar 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class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1' class='payment_form' action='\/en\/wp-json\/wp\/v2\/pages\/4889' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_35'>\u8a02\u55ae\u7de8\u865f<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_1_35' type='text' value='d01-14832' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_15\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'>Hospital Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_15' id='input_1_15' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select County\/City <\/option><option value='Keelung City' >Keelung City<\/option><option value='Taipei City' >Taipei City<\/option><option value='New Taipei City' >New Taipei City<\/option><option value='Taoyuan City' >Taoyuan City<\/option><option value='Hsinchu County\/City' >Hsinchu County\/City<\/option><option value='Miaoli County' >Miaoli County<\/option><option value='Taichung City' >Taichung City<\/option><option value='Changhua County' >Changhua County<\/option><option value='Nantou County' >Nantou County<\/option><option value='Yunlin County' >Yunlin County<\/option><option value='Chiayi County' >Chiayi County<\/option><option value='Tainan City' >Tainan City<\/option><option value='Kaohsiung City' >Kaohsiung City<\/option><option value='Pingtung County' >Pingtung County<\/option><option value='\u5b9c\u862d\u7e23' >\u5b9c\u862d\u7e23<\/option><option value='\u53f0\u6771\u7e23' >\u53f0\u6771\u7e23<\/option><option value='\u82b1\u84ee\u7e23' >\u82b1\u84ee\u7e23<\/option><option value='\u5176\u5b83' >\u5176\u5b83<\/option><\/select><\/div><\/div><div id=\"field_1_34\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_34'>Select Hospital<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_34' id='input_1_34' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Hospital<\/option><\/select><\/div><\/div><div id=\"field_1_16\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>\u57fa\u9686<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_1_16' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Hospital<\/option><option value='Keelung Hospital, MOHW' >Keelung Hospital, MOHW<\/option><\/select><\/div><\/div><div id=\"field_1_18\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'>\u53f0\u5317<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_1_18' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Hospital<\/option><option value='Shin Kong Wu Ho-Su Memorial Hospital' >Shin Kong Wu Ho-Su Memorial Hospital<\/option><option value='Taipei City Hospital, Renai Branch' >Taipei City Hospital, Renai Branch<\/option><option value='Cathay General Hospital' >Cathay General Hospital<\/option><option value='\u53f0\u5317\u99ac\u5055\u5152\u7ae5\u91ab\u9662' >\u53f0\u5317\u99ac\u5055\u5152\u7ae5\u91ab\u9662<\/option><option value='\u53f0\u5317\u99ac\u5055\u7d00\u5ff5\u91ab\u9662' >\u53f0\u5317\u99ac\u5055\u7d00\u5ff5\u91ab\u9662<\/option><option value='\u570b\u7acb\u81fa\u7063\u5927\u5b78\u91ab\u5b78\u9662\u9644\u8a2d\u91ab\u9662' >\u570b\u7acb\u81fa\u7063\u5927\u5b78\u91ab\u5b78\u9662\u9644\u8a2d\u91ab\u9662<\/option><option value='\u570b\u7acb\u81fa\u7063\u5927\u5b78\u91ab\u5b78\u9662\u9644\u8a2d\u91ab\u9662\u897f\u5740(\u820a\u9662)' >\u570b\u7acb\u81fa\u7063\u5927\u5b78\u91ab\u5b78\u9662\u9644\u8a2d\u91ab\u9662\u897f\u5740(\u820a\u9662)<\/option><option value='\u570b\u7acb\u81fa\u7063\u5927\u5b78\u91ab\u5b78\u9662\u9644\u8a2d\u91ab\u9662\u764c\u91ab\u4e2d\u5fc3\u5206\u9662' >\u570b\u7acb\u81fa\u7063\u5927\u5b78\u91ab\u5b78\u9662\u9644\u8a2d\u91ab\u9662\u764c\u91ab\u4e2d\u5fc3\u5206\u9662<\/option><option value='\u570b\u7acb\u81fa\u7063\u5927\u5b78\u91ab\u5b78\u9662\u9644\u8a2d\u91ab\u9662\u5152\u7ae5\u91ab\u9662' >\u570b\u7acb\u81fa\u7063\u5927\u5b78\u91ab\u5b78\u9662\u9644\u8a2d\u91ab\u9662\u5152\u7ae5\u91ab\u9662<\/option><option value='\u81fa\u5317\u5e02\u7acb\u806f\u5408\u91ab\u9662 \u548c\u5e73\u5a66\u5e7c\u9662\u5340' >\u81fa\u5317\u5e02\u7acb\u806f\u5408\u91ab\u9662 \u548c\u5e73\u5a66\u5e7c\u9662\u5340<\/option><option value='\u597d\u5fc3\u809d\u8a3a\u6240' >\u597d\u5fc3\u809d\u8a3a\u6240<\/option><option value='\u4e2d\u5fc3\u7d9c\u5408\u91ab\u9662' >\u4e2d\u5fc3\u7d9c\u5408\u91ab\u9662<\/option><option value='\u5167\u6e56\u4e09\u8ecd\u7e3d\u91ab\u9662' >\u5167\u6e56\u4e09\u8ecd\u7e3d\u91ab\u9662<\/option><option value='\u81fa\u5317\u5e02\u7acb\u842c\u82b3\u91ab\u9662' >\u81fa\u5317\u5e02\u7acb\u842c\u82b3\u91ab\u9662<\/option><option value='\u81fa\u5317\u69ae\u6c11\u7e3d\u91ab\u9662' >\u81fa\u5317\u69ae\u6c11\u7e3d\u91ab\u9662<\/option><option value='\u548c\u4fe1\u6cbb\u764c\u4e2d\u5fc3\u91ab\u9662' >\u548c\u4fe1\u6cbb\u764c\u4e2d\u5fc3\u91ab\u9662<\/option><option value='\u632f\u8208\u91ab\u7642\u8ca1\u5718\u6cd5\u4eba\u632f\u8208\u91ab\u9662' >\u632f\u8208\u91ab\u7642\u8ca1\u5718\u6cd5\u4eba\u632f\u8208\u91ab\u9662<\/option><option value='\u81fa\u5317\u91ab\u5b78\u5927\u5b78\u9644\u8a2d\u91ab\u9662' >\u81fa\u5317\u91ab\u5b78\u5927\u5b78\u9644\u8a2d\u91ab\u9662<\/option><option value='\u81fa\u5317\u5e02\u7acb\u806f\u5408\u91ab\u9662 \u5fe0\u5b5d\u9662\u5340' >\u81fa\u5317\u5e02\u7acb\u806f\u5408\u91ab\u9662 \u5fe0\u5b5d\u9662\u5340<\/option><option value='\u74bd\u611b\u8a3a\u6240' >\u74bd\u611b\u8a3a\u6240<\/option><option value='\u5176\u4ed6\u9662\u6240\/\u8a3a\u6240' >\u5176\u4ed6\u9662\u6240\/\u8a3a\u6240<\/option><\/select><\/div><\/div><div id=\"field_1_17\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_17'>\u65b0\u5317<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_1_17' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Hospital<\/option><option value='En Chu Kong Hospital' >En Chu Kong Hospital<\/option><option value='New Taipei Municipal TuCheng Hospital' >New Taipei Municipal TuCheng Hospital<\/option><option value='Shuang-Ho Hospital, MOHW' >Shuang-Ho Hospital, MOHW<\/option><option value='Far Eastern Memorial Hospital' >Far Eastern Memorial Hospital<\/option><option value='NTU Jin-Shan Branch' >NTU Jin-Shan Branch<\/option><option value='Fu Jen Catholic University Hospital' >Fu Jen Catholic University Hospital<\/option><option value='Tamshui Mackay Memorial Hospital' >Tamshui Mackay Memorial Hospital<\/option><option value='Cardinal Tien Hospital' >Cardinal Tien Hospital<\/option><option value='Taipei Tzu Chi Hospital' >Taipei Tzu Chi Hospital<\/option><option value='Taipei Hospital, MOHW' >Taipei Hospital, MOHW<\/option><\/select><\/div><\/div><div id=\"field_1_19\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_19'>\u6843\u5712<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_1_19' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Hospital<\/option><option value='Landseed International Hospital' >Landseed International Hospital<\/option><option value='Taoyuan Armed Forces General Hospital' >Taoyuan Armed Forces General Hospital<\/option><option value='Linkou Chang Gung Memorial Hospital' >Linkou Chang Gung Memorial Hospital<\/option><option value='\u4e2d\u7f8e\u91ab\u9662' >\u4e2d\u7f8e\u91ab\u9662<\/option><\/select><\/div><\/div><div id=\"field_1_21\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_21'>Hsinchu County\/City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_1_21' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Hospital<\/option><option value='NTU Hsin-Chu Hospital' >NTU Hsin-Chu Hospital<\/option><option value='Hsinchu MacKay Memorial Hospital' >Hsinchu MacKay Memorial Hospital<\/option><option value='Hsinchu Municipal MacKay Children&#039;s Hospital' >Hsinchu Municipal MacKay Children&#039;s Hospital<\/option><option value='NTU BioMedical Park Hospital' >NTU BioMedical Park Hospital<\/option><option value='China Medical University Hsinchu Hospital' >China Medical University Hsinchu Hospital<\/option><\/select><\/div><\/div><div id=\"field_1_22\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_22'>\u82d7\u6817<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_1_22' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Hospital<\/option><option value='Da Chien General Hospital' >Da Chien General Hospital<\/option><\/select><\/div><\/div><div id=\"field_1_23\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_23'>\u53f0\u4e2d<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_1_23' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Hospital<\/option><option value='Taichung Armed Forces General Hospital' >Taichung Armed Forces General Hospital<\/option><option value='China Medical University Hospital' >China Medical University Hospital<\/option><option value='CMU Children&#039;s Hospital' >CMU Children&#039;s Hospital<\/option><option value='Taichung Veterans General Hospital' >Taichung Veterans General Hospital<\/option><option value='Taichung Hospital, MOHW' >Taichung Hospital, MOHW<\/option><option value='Kuang-Tien General Hospital Shalu Division' >Kuang-Tien General Hospital Shalu Division<\/option><option value='Kuang-Tien General Hospital Dajia Division' >Kuang-Tien General Hospital Dajia Division<\/option><option value='Chung Shan Medical University Hospital' >Chung Shan Medical University Hospital<\/option><option value='Tungs&#039; Taichung Metroharbor Hospital' >Tungs&#039; Taichung Metroharbor Hospital<\/option><option value='Jia Sin Clinic' >Jia Sin Clinic<\/option><option value='Taichung Tzu Chi Hospital' >Taichung Tzu Chi Hospital<\/option><option value='Asia University Hospital' >Asia University Hospital<\/option><\/select><\/div><\/div><div id=\"field_1_24\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_24'>\u5f70\u5316<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_24' id='input_1_24' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Hospital<\/option><option value='Yuanlin Christian Hospital' >Yuanlin Christian Hospital<\/option><option value='Chang Bing Show Chwan Memorial Hospital' >Chang Bing Show Chwan Memorial Hospital<\/option><option value='Show Chwan Memorial Hospital' >Show Chwan Memorial Hospital<\/option><option value='Changhua Christian Children&#039;s Hospital' >Changhua Christian Children&#039;s Hospital<\/option><option value='Changhua Christian Hospital' >Changhua Christian Hospital<\/option><\/select><\/div><\/div><div id=\"field_1_26\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_26'>\u5357\u6295<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_1_26' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Hospital<\/option><option value='Nantou Hospital, MOHW' >Nantou Hospital, MOHW<\/option><\/select><\/div><\/div><div id=\"field_1_25\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_25'>\u96f2\u6797<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_1_25' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Hospital<\/option><option value='NTU Hospital Yunlin Branch Douliu Division' >NTU Hospital Yunlin Branch Douliu Division<\/option><\/select><\/div><\/div><div id=\"field_1_27\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_27'>\u5609\u7fa9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_27' id='input_1_27' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Hospital<\/option><option value='St. Martin De Porres Hospital' >St. Martin De Porres Hospital<\/option><option value='Chia-Yi Christian Hospital' >Chia-Yi Christian Hospital<\/option><option value='Dalin Tzu Chi Hospital' >Dalin Tzu Chi Hospital<\/option><option value='Chiayi Chang Gung Memorial Hospital' >Chiayi Chang Gung Memorial Hospital<\/option><\/select><\/div><\/div><div id=\"field_1_28\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_28'>\u53f0\u5357<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_28' id='input_1_28' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Hospital<\/option><option value='National Cheng Kung University Hospital' >National Cheng Kung University Hospital<\/option><option value='Chi Mei Medical Center' >Chi Mei Medical Center<\/option><option value='Tainan Sin-Lau Hospital' >Tainan Sin-Lau Hospital<\/option><option value='Tainan Municipal Hopsital' >Tainan Municipal Hopsital<\/option><option value='Chi Mei Hospital, Liouying' >Chi Mei Hospital, Liouying<\/option><\/select><\/div><\/div><div id=\"field_1_29\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_29'>\u9ad8\u96c4<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_29' id='input_1_29' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Hospital<\/option><option value='KMU Chung-Ho Memorial Hospital' >KMU Chung-Ho Memorial Hospital<\/option><option value='Kaohsiung Veterans General Hospital' >Kaohsiung Veterans General Hospital<\/option><option value='Kaohsiung Municipal Ta-Tung Hospital' >Kaohsiung Municipal Ta-Tung Hospital<\/option><option value='Kaoshiung Chang Gung Memorial Hospital' >Kaoshiung Chang Gung Memorial Hospital<\/option><option value='E-Da Hospital' >E-Da Hospital<\/option><\/select><\/div><\/div><div id=\"field_1_30\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>\u5c4f\u6771<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_30' id='input_1_30' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Hospital<\/option><option value='Pingtung Hospital, MOHW' >Pingtung Hospital, MOHW<\/option><\/select><\/div><\/div><div id=\"field_1_40\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_40'>\u5b9c\u862d<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_40' id='input_1_40' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>\u9078\u9662\u6240<\/option><option value='\u7f85\u6771\u8056\u6bcd\u91ab\u9662' >\u7f85\u6771\u8056\u6bcd\u91ab\u9662<\/option><\/select><\/div><\/div><div id=\"field_1_31\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_31'>\u53f0\u6771<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_31' id='input_1_31' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Hospital<\/option><option value='Taitung MacKay Memorial Hospital' >Taitung MacKay Memorial Hospital<\/option><\/select><\/div><\/div><div id=\"field_1_32\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_32'>\u82b1\u84ee<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_1_32' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Hospital<\/option><option value='Hualien Tzu Chi Hospital' >Hualien Tzu Chi Hospital<\/option><option value='Hualien Armed Forces General Hospital' >Hualien Armed Forces General Hospital<\/option><\/select><\/div><\/div><div id=\"field_1_41\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half select_hospital gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_41'>\u5176\u5b83<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_41' id='input_1_41' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>\u9078\u9662\u6240<\/option><option value='\u5176\u5b83' selected='selected'>\u5176\u5b83<\/option><\/select><\/div><\/div><div id=\"field_1_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_13'>Attending Physician<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='large'    placeholder='Please enter the name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'>Patient Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='large'    placeholder='Please enter the patient&#039;s name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Payer Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'   placeholder='Please enter the name'  \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_1_2\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_2'>Payer Mobile Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_2' id='input_1_2' type='tel' value='' class='large'  placeholder='Please enter the mobile number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_3\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_1_3' type='email' value='' class='large'   placeholder='Please enter your email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_1_4\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-half gfield_contains_required field_sublabel_hidden_label gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Mailing Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street ginput_container_address gform-grid-row' id='input_1_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_4_1_container' >\n                                        <input type='text' name='input_4.1' id='input_1_4_1' value=''   placeholder='Please enter the name' aria-required='true'    \/>\n                                        <label for='input_1_4_1' id='input_1_4_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><input type='hidden' class='gform_hidden' name='input_4.4' id='input_1_4_4' value=''\/><input type='hidden' class='gform_hidden' name='input_4.6' id='input_1_4_6' value='Taiwan' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><div class='gfield_description' id='gfield_description_1_4'>*Paper reports and invoices will be mailed to this address.<\/div><\/fieldset><div id=\"field_1_6\" class=\"gfield gfield--type-product gfield--input-type-price gfield--width-full gfield_price gfield_price_1_6 gfield_product_1_6 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>Total Payment Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_product_price'>\n\t\t\t\t\t<input name='input_6' id='input_1_6' type='text' value='' class='large ginput_amount'  placeholder='0' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_1_6\" \/>\n\t\t\t\t<\/div><div class='gfield_description' id='gfield_description_1_6'>Please confirm the payment amount with hospital staff.<\/div><\/div><fieldset id=\"field_1_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full column-direction gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Payment Method<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_9'>\n\t\t\t<div class='gchoice gchoice_1_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='\u7dda\u4e0a\u5237\u5361\/ATM\u4ed8\u6b3e\/WebATM\/\u8d85\u5546\u4ed8\u6b3e' checked='checked' id='choice_1_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_9_0' id='label_1_9_0' class='gform-field-label gform-field-label--type-inline'>\u7dda\u4e0a\u5237\u5361\/ATM\u4ed8\u6b3e\/WebATM\/\u8d85\u5546\u4ed8\u6b3e<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full column-direction invoice_block gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Invoice<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_11'>\n\t\t\t<div class='gchoice gchoice_1_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Paper Invoice'  id='choice_1_11_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_11\"   \/>\n\t\t\t\t\t<label for='choice_1_11_0' id='label_1_11_0' class='gform-field-label gform-field-label--type-inline'>Paper Invoice<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Digital Carrier'  id='choice_1_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_1' id='label_1_11_1' class='gform-field-label gform-field-label--type-inline'>Digital Carrier<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_11'>\u5982\u6709\u7533\u8acb\u4fdd\u96aa\u9700\u6c42\u8acb\u6ce8\u610f\uff1a<br>\n\u6839\u64da\u8ca1\u653f\u90e8\u4ee4\u53f0\u8ca1\u8cc7\u5b57\u7b2c1020002795\u865f\u300c\u96fb\u5b50\u767c\u7968\u5be6\u65bd\u4f5c\u696d\u8981\u9ede\u300d\uff0c\u7531\u65bc\u7cfb\u7d71\u9650\u5236\uff0c\u4f7f\u7528\u96fb\u5b50\u767c\u7968\u8f09\u5177\u78bc\u7121\u6cd5\u63d0\u4f9b\u7d19\u672c\u767c\u7968\u526f\u672c\uff0c\u8acb\u81ea\u884c\u4e0b\u8f09\u5217\u5370\u3002<\/div><\/fieldset><div id=\"field_1_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_33'>\u96fb\u5b50\u767c\u7968\u8f09\u5177\u78bc<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_1_33' type='text' value='' class='large'    placeholder='\u8acb\u8f38\u5165' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u662f\u5426\u9700\u8981\u8acb\u9818\u4fdd\u96aa<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_37'>\n\t\t\t<div class='gchoice gchoice_1_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='\u662f'  id='choice_1_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_0' id='label_1_37_0' class='gform-field-label gform-field-label--type-inline'>\u662f<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='\u5426'  id='choice_1_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_1' id='label_1_37_1' class='gform-field-label gform-field-label--type-inline'>\u5426<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_12\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>Invoice Copies<\/label><div class='ginput_container ginput_container_select'><select name='input_12' id='input_1_12' class='large gfield_select'     aria-invalid=\"false\" ><option value='0' >0<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><\/select><\/div><\/div><div id=\"field_1_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_36'>\u767c\u7968\u62ac\u982d\uff0f\u7d71\u7de8<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_1_36' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_36\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_36'>\u5982\u6709\u7533\u8acb\u4fdd\u96aa\u9700\u6c42\u8acb\u6ce8\u610f\uff0c\u767c\u7968\u4e0d\u53ef\u6253\u62ac\u982d\u3001\u7d71\u7de8<\/div><\/div><fieldset id=\"field_1_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u767c\u7968\u683c\u5f0f<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_38'>\n\t\t\t<div class='gchoice gchoice_1_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='\u4e8c\u806f\u5f0f\u767c\u7968'  id='choice_1_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_38_0' id='label_1_38_0' class='gform-field-label gform-field-label--type-inline'>\u4e8c\u806f\u5f0f\u767c\u7968<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='\u4e09\u806f\u5f0f\u767c\u7968'  id='choice_1_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_38_1' id='label_1_38_1' class='gform-field-label gform-field-label--type-inline'>\u4e09\u806f\u5f0f\u767c\u7968<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit your Form'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='TWD' value='T5vg504sUGTt\/PrDolG4tlN487o7n8yxBP49qziSYpX5UaKjRZG81NJM9aqjzjJhpB9un15uW2IlNlsOJb+PDdacuNGzVWYphljuphFPh2hOtXY=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' 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